Cpr duration and outcome
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CPR: Duration and Outcome. Jack P Freer, MD Professor of Clinical Medicine Daniel J Miori MS, RPA-C Palliative and Ethics Millard Fillmore Gates Daniel Sleve, M4. CPR. Unique —high stakes, life or death, stark Abrupt —must be refused in advance Standardized —routine, ACLS protocol

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CPR: Duration and Outcome

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Cpr duration and outcome

CPR: Duration and Outcome

Jack P Freer, MD

Professor of Clinical Medicine

Daniel J Miori MS, RPA-C

Palliative and Ethics

Millard Fillmore Gates

Daniel Sleve, M4


Cpr duration and outcome

CPR

  • Unique—high stakes, life or death, stark

  • Abrupt—must be refused in advance

  • Standardized—routine, ACLS protocol

  • Universal—potential use: everyone

  • Iconic—represents promise and misuse of modern technical medical capabilities


Cpr decision making

CPR Decision Making

  • Presumption to treat

  • No decision=consent to CPR

  • Documentation regulated


Reasons to use cpr

Reasons to Use CPR

  • Benefits > Burdens

    • It’s good to be alive!

    • Burdens trivial by comparison

  • Desperation


Reasons to refuse cpr consent to dnr

Reasons to Refuse CPR(consent to DNR)

  • Little empirical data in literature

  • Theoretical construct

    • Tomlinson T. Brody H. Ethics and Communication in Do-Not-Resuscitate Orders.NEJM(1988) 318:43-6

  • NYS DNR Law

  • Symbolism

  • Cynical view


Reasons to refuse cpr tomlinson brody

Reasons to Refuse CPRTomlinson & Brody

  • No Medical Benefit—Futile

  • Poor Quality of Life after CPR—CNS damage, life support etc

  • Poor Quality of Life before CPR—It’s NOT good to be alive


Reasons to refuse cpr

Reasons to Refuse CPR

  • Patient is Dying—”Dying” causes cardiac arrest (not other way around)

  • Poor Quality of Life after CPR— Clinical determination (+ pt/surrogate)

  • Poor Quality of Life before CPR — Patient/surrogate assessment


Nys dnr law

NYS DNR Law

(c) A surrogate may consent to an order not to resuscitate on behalf of an adult patient only if there has been a determination by an attending physician with the concurrence of another physician selected by a person authorized by the hospital to make such selection, given after personal examination of the patient that, to a reasonable degree of medical certainty:


Nys dnr law1

NYS DNR Law

  • the patient has a terminal condition; or

  • the patient is permanently unconscious; or

  • resuscitation would be medically futile; or

  • resuscitation would impose an extraordinary burden on the patient in light of the patient's medical condition and the expected outcome of resuscitation for the patient.


Symbolic nature of cpr

Symbolic Nature of CPR

  • Icon of aggressive care—both good and bad

    • Full code = fighting back

    • DNR = giving up


Symbolic nature of cpr1

Symbolic Nature of CPR

  • Patient/Family Attitude—doubtful that patient/family who wish full code really accept reality of fatal illness

  • Physician/Staff Attitude—presence of DNR order implies desire for less aggressive treatment in other realms


Dnr and non cpr care

DNR and non-CPR Care

  • Physician/Staff Attitude—presence of DNR order implies desire for less aggressive treatment in other realms

  • Beach MC, Morrison SR, The Effect of Do-Not-Resuscitate Orders on Physician Decision-Making. J Am Geriatr Soc (2002) 50:2057–2061,.


Dnr and non cpr care beach and morrison

DNR and non-CPR CareBeach and Morrison

  • Physician survey

  • 3 Clinical vignettes

  • 2 Versions of each

    • One with DNR

    • Other no DNR

  • Sequential treatment decisions


Dnr and non cpr care beach and morrison1

DNR and non-CPR CareBeach and Morrison


Reasons to refuse cpr1

Reasons to Refuse CPR

Cynical

  • Because the physician approaching the patient/family thinks it’s a good idea and persuades the decision maker

  • Gory details (“break your ribs”)

  • Often no mention of survival/outcome data


Rational approach

Rational Approach

Choudhry NK, Choudhry S, Singer PA.CPR for Patients Labeled DNR: The Role of the Limited Aggressive Therapy Order. Ann Intern Med (2003) 138:65-68.

  • Presumes people make DNR decisions based on probability of poor outcome with CPR.

  • Overlooks high-yield circumstances (relatively good outcomes with CPR):

    • Witnessed “shockable” rhythms

    • CPR in OR

    • Iatrogenic/procedures


Rational approach1

Rational Approach

  • Witnessed “shockable” rhythms

  • CPR in OR

  • Iatrogenic/procedures

    Choudhry:

  • LATO order: Limited aggressive therapy;

  • Intermediate status.

  • Unwieldy

    Short Code.


Code duration and outcome

Code Duration and Outcome

  • Variety of outcome measures

    • Restoration of spontaneous circulation

    • Survival at 24 hours

    • Survival to discharge

  • Variety of timeframes

    • < or > 5, 10, 15, 20 min

    • Ranges (5-10, 11-15, 16-20 etc)

    • Mean CPR time among survival


Short code

Short Code

  • Allows patient to avoid outcomes of prolonged code

  • Eliminates generalizing DNR to other decisions

  • NOT a sham code ( “slow code,” “show code”)

  • NOT a partial code (“CPR but DNI”)

  • Go all out—but for less time

  • No confusion in initiating code

  • No confusion in running of code

  • No confusion in ending code


Cooper cade 1997

Cooper & Cade 1997


Millard gates 12 06 12 07

Millard Gates 12/06 – 12/07


Survived procedure

Survived Procedure


Survived 24 hours

Survived 24 Hours


Survived to discharge

Survived to Discharge


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