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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

Jack P Freer, MD

Professor of Clinical Medicine

Daniel J Miori MS, RPA-C

Palliative and Ethics

Millard Fillmore Gates

Daniel Sleve, M4


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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


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CPR Decision Making

  • Presumption to treat

  • No decision=consent to CPR

  • Documentation regulated


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Reasons to Use CPR

  • Benefits > Burdens

    • It’s good to be alive!

    • Burdens trivial by comparison

  • Desperation


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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


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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


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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


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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:


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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.


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Symbolic Nature of CPR

  • Icon of aggressive care—both good and bad

    • Full code = fighting back

    • DNR = giving up


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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


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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,.


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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


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DNR and non-CPR CareBeach and Morrison


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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


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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


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Rational Approach

  • Witnessed “shockable” rhythms

  • CPR in OR

  • Iatrogenic/procedures

    Choudhry:

  • LATO order: Limited aggressive therapy;

  • Intermediate status.

  • Unwieldy

    Short Code.


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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


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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







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