It is time to publicly and privately discuss the limits of cardiopulmonary resuscitation, known as CPR, so patients stricken with COVID-19 can make informed end-of-life decisions and make those decisions known to their closest relatives.
In anticipation of the pandemic surge, hospitals are discussing blanket do-not-resuscitate (DNR) orders for patients dying from the coronavirus. These conversations are being driven by concerns about the limited value of resuscitation efforts among these patients. In addition “code blue” CPR efforts typically involve 8-30 clinicians rushing to the patient’s bedside, thus increasing the risk to hospital staff at a time when hospitals are dealing with dwindling supplies of protective equipment.
A whispered secret in medicine is that resuscitative efforts do not typically save a life. When you took the mandatory CPR class to become a lifeguard or babysitter, they probably skipped over these stats. But outside the hospital, the survival rate of resuscitative efforts is dismal. Thumping the chest with or without blowing air in the lungs brings about 1-8% of people back, more if automatic external defibrillators are available. In-hospitals the survival rate hovers around 20%, but the success varies greatly based on underlying condition. The coronavirus patients ending up in ICU’s typically have multi-organ failure, respiratory failure, and septic shock.
Influenced by TV hospital dramas where the medical hero almost always snatches life from the jaws of death, people tend to have unrealistic expectations and overestimate their chances of survival after CPR. Most such patients do not live to walk out of the hospital and instead succumb to complications of their illness. Moreover, resuscitative efforts are harsh especially for older patients, often resulting in painful broken ribs or a cracked sternum. Some patients will end in a coma or survive with cognitive problems and a rapidly diminished quality of life. Physicians know these ugly statistics. No wonder most doctors would forego CPR for themselves and their loved ones if they were dying from a terminal illness.
In fact, six months ago, one of us confronted this decision in the most personal of ways. Chloe’s husband elected DNR at a point when his health was declining but still fair. As a physician, his choice was not to forgo treatment from which he could benefit, but rather to close off one path that he knew was likely to contribute to a bad death. When the time came, knowing his preferences provided comfort to him and the family.
Regardless of the pandemic, keeping our health care workers safe and healthy should always be the top priority. From a medical perspective, it may make sense to avoid futile efforts and to provide a policy that guides treatment decisions and prevents individual clinicians having to repeatedly make the call not to attempt resuscitation. And for patients kept isolated in the hospital, being brought back only to extend dying while gasping for air may be the epitome of a bad death.
Blanket DNR proposals may feel like nightmare flashbacks to paternalistic medicine of a century ago when physicians decided unilaterally what was best for patients regardless of what patients preferred. It doesn’t need to be this way. In the age of patient-centered medicine and shared decision-making, we each have to do our part. Now is the time to make your wishes about the end-of-life known to your family and your physician. If you don’t talk with your family about this now, you may have a much more challenging conversation under constrained circumstances.
While physical distancing requirements may make it impossible to contact a lawyer or to sit down with your physician, you can find advance directive forms online that give you step-by-step advice on where you want to draw the line. While thinking through the different scenarios, you may want to consult with your relatives and, of course, you will need to tell them what you want and keep the form handy. The advance directive may not just minimize the trauma of health care providers contemplating when to respond aggressively. It could be a gift to you and to those left behind to grieve you. Knowing that your wishes were followed may give everyone peace of mind.
Stefan Timmermans is a professor at the UCLA Department of Sociology and the author of Sudden Death and the Myth of CPR. Chloe E. Bird is a senior sociologist at the nonprofit, nonpartisan RAND Corporation.