Multiple Cardiopulmonary Resuscitation Attempts in a Community Hospital

Abstract

Background:

In hospital settings, inadequate recognition of futility of aggressive medical management in patients with terminal disease and lack of the timely transition to palliative care may lead to both excessive and potentially harmful treatment and unnecessary burden on hospital resources. In order to better understand the outcomes of futile medical management and recognize the need for more appropriate end-of-life care, we evaluated the survival of particularly vulnerable cohort of patients in a community hospital who had survived at least 1 cardiorespiratory arrest (CRA) but whose medical problems led to subsequent arrests.

Methods:

In this retrospective cohort study, we have reviewed the annual cardiopulmonary resuscitation (CPR) data in a community hospital in urban settings.

Results:

Analyzing the population of all patients who had CRA, 22.4% had more than 1 CRA episode and had multiple CPRs (42% of all inpatient CPR were performed on this group of patients). Overall survival at the discharge of patients who had single CRA is significantly better than survival at the discharge of patients who had more than 1 CRA episode (31% vs 4.5%). Only 18.5% of the patients who initially survived CPR after CRA were transitioned to “do not resuscitate” status subsequently, while vast majority had continued aggressive resuscitative efforts.

Conclusion:

Adjusting medical care based on futility assessment in patients with chronic illness who survive CRA is often neglected, but crucially relevant step in the optimization of health care system management.

Keywords

futility cardiopulmonary resuscitation resuscitation cardiorespiratory (cardiac) arrest

Introduction

Although futility in medicine is an ancient concept,¹ systematic approach to futility assessment has become an increasingly important part of treatment in critical care medicine more recently. This concept emerged in the 1980s in response to the concern about families who demanded life-prolonging treatments for their loved ones opposing the physician caregivers who deemed this to be inappropriate.² The attempts to define the concept of futility and develop institutional and legislative procedures addressing it^3
–5 had variable impact on medical community to recognize its significance.^6,7 Despite the fact that majority of states within the United States have enacted medical futility statutes to permit the health care provider to refuse a patient’s request for life-sustaining medical treatment,⁵ evidence-based data defining futility is largely missing and futility assessment is often marginalized in hospital settings.⁶ Looking broader, the understanding of medical futility in a society is generally missing even more. Survival rates after cardiopulmonary resuscitation (CPR) as seen on television are significantly higher than the most optimistic survival rates in the medical literature.⁸ This often leads the viewing public to an unrealistic impression of CPR and its chances for success. When chances of surviving the CPR are analyzed in the population with chronical illness and their families, the discrepancy between media-driven impression of CPR and the reality becomes even more dramatic.⁹

Cardiopulmonary resuscitation represents the standard of care for a patient with cardiorespiratory arrest (CRA). The public awareness about it has raised significantly over the years, leading to the ability to quickly intervene in cases of out-of-hospital cardiac arrests.¹⁰ This has further led to the understanding that focusing on optimizing outcomes beyond return of spontaneous circulation and return to a prior quality of life and functional state of health has been the ultimate goal of a resuscitation system of care.^11
–13 In the published literature, survival rates range between 1% and 43%,^{14

–21} varying broadly²² due to multiple factors including the settings where the CPR is being conducted, the duration of CRA, its etiology, initial cardiac rhythm, and patient comorbidities. In early stages of application of CPR on a patient with cardiac arrest, over 50 years ago, CPR was “indicated for the patient who, at the time of cardiopulmonary arrest, is not in the terminal stage of an incurable disease.”²³ It was understood that resuscitative measures on terminal patients can, at best, return them to the dying state, so the recommended approach for a physician was to concentrate on resuscitating patients who were in good health preceding the arrest and who are likely to resume a normal existence.^23,24,25 Although designed as a life-saving measure, CPR is often used in inadequate clinical scenarios, further leading to futile and potentially harmful management of a terminally ill patient with CRA. Inappropriately used CPR carries additional unnecessary burden on hospital or clinic resources. Cardiopulmonary resuscitation, as any other medical intervention, should be evaluated for the benefits and risks prior to being applied, and this evaluation needs to be done in every particular case in a manner appropriate to the circumstances.^26,27

In this study, we retrospectively analyze a cohort of patients in a community hospital who had survived at least 1 CRA but whose medical problems led to subsequent arrests. We analyzed the outcome of this treatment approach in search for reliable indicators of futility. We also look for the reasons for inappropriate futility assessment in cases where prolonged and aggressive treatment did not show favorable outcome.

Methods

In this retrospective cohort study, we reviewed the CPR data at Cabrini Medical Center, Manhattan, New York, between January 1, 2006, and January 1, 2007. As required, resuscitation was attempted for each CRA of a patient without a signed “Do Not Resuscitate” (DNR) form and the information about each resuscitation attempt was collected. We first reviewed resuscitation review and code (CPR) sheet forms completed after attempted resuscitation. The following data were collected: date and exact time the code was called, location of the code (intensive care settings/medical floors/emergency department/other), and the outcome (alive/dead).

After assembling the database of all patients who had CRA during 2006, we focused on patients who coded more than once. Successfully performed CPR with return of spontaneous circulation and relative hemodynamic stability in at least 30 minutes after CPR termination was a criterion used to define a CPR survival. For the selected group of patients who were resuscitated more than once, we looked into medical records for patients’ age, ethnicity, principal diagnosis and comorbidities, living situation before hospitalization, advance directives’ assessment and code status, patient prognosis discussions, and reasons for continuation of resuscitation efforts to determine factors that were associated with multiple resuscitative efforts. Proportions were compared with chi-square or Fisher Exact test where appropriate.

Results

A total of 135 codes for CRA were collected at the Cabrini Medical Center in 2006. Of all the patients subjected to CPR measures (98 patients), 22 (22.4%) underwent multiple attempts of CPR (Table 1). The 57 CPRs that were performed on 22 patients comprises 42.2% of all hospital CPRs; in other words, 35 CRAs (26% of all CRAs) were repeated episodes. An average number of CPR performed on a patient who had more than 1 CRA was 2.6 and this number ranged from 2 to 7 in our cohort. Comparing survival at the discharge between all patients who had CRA and who had CPR performed (31%) and survival at the discharge of subgroup of patients who had multiple arrests (4.5%), we find significantly poorer survival results in the latter (χ² = 6.37, P = .016; Figure 1). The mean age of the patients who underwent multiple CPR was 68.2 years and 50% were males. Of these patients, 61% required significant assistance with activities of daily living prior to hospital admission. The majority (86%) of these codes happened in monitored unit settings (intensive/cardiac care unit or emergency department), while 14% happened in nonmonitored hospital settings (medical floors, radiology department, and transport). The length of hospital stay prior to the first code was longer than 24 hours in 77% of the cases. Survival time between the codes ranged from 30 minutes to 131 days, but in 74% of the cases, the following code happened within 24 hours from the previous code. Of 22 patients, 21 died during the hospitalization and 1 patient was transferred to skilled nursing facility in a comatose, vegetative state.

Table 1.

Demographic and Clinical Data Collected for Patients Resuscitated More Than Once in Cabrini Medical Center in 2006.

Patients with multiple cardiorespiratory arrest episodes
Pt	Sex (M/F)	Age	Hospitalization day of the first CRA episode	Number of CRA episodes	Outcome at the discharge	Time interval between 2 CRAs	Code location	Cause of death/significant chronic condition	PCP involved	Religion	Race	Prehospitalization condition	Patient directives on admission	Prognosis discussion documented
1	M	33	56	3	Dead	CRA 1: 15 h	ED × 1	Septic shock	No	None	Caucasian	Independent living	Unable to obtain	No
1	M	33	56	3	Dead	CRA 2: 0.5 h	ICU × 2	Septic shock	No	None	Caucasian	Independent living	Unable to obtain	No
2	M	61	72	3	Alive	CRA 1: 10 days,	ICU × 3	Septic shock/profound debilitation with multiple medical problems	Yes	Protestant	African American	Wheelchair-bound	Full code	Yes
2	M	61	72	3	Alive	CRA 2: 62 days	ICU × 3		Yes	Protestant	African American	Wheelchair-bound	Full code	Yes
3	F	77	30	4	Dead	CRA 1:10 days	GMF × 1, CCU × 3	Fulminant liver failure	Yes	Catholic	African American	Independent living	Full code	No
						CRA 2: 19 days
						CRA 3: 1 h
4	M	78	1	2	Dead	0.6 h	CCU × 2	Acute respiratory failure/end-stage metastatic cryptogenic adenocarcinoma	Yes	Catholic	Hispanic	Independent living	Full code	yes
5	F	86	13	2	Dead	2 h	CCU × 2	Myocardial infarction with myocardial rupture/profound debilitation with multiple medical problems	Yes	Protestant	Caucasian	Bedbound	Unable to obtain	No
6	F	72	25	2	Dead	2 h	GMF × 1, ICU × 1	Septic shock	Yes	Catholic	Hispanic	Independent living	Full code	Yes
7	F	83	8	2	Dead	1.25h	GMF × 1, ICU × 1	Septic shock, ARDS	Yes	Catholic	Hispanic	Unknown	Full code	No
8	F	87	1	2	Dead	1h	ED × 2	Pulmonary embolism	No	N/K	Caucasian	Unknown	Full code	No
9	M	77	12	4	Dead	CRA 1: 9 h	ICU × 4	Septic shock/profound debilitation, chronic ventilator dependance	Yes	None	Asian	Ventilator dependant, SNF resident	Full code	No
						CRA 2: 2.5 h
						CRA 3: 0.5 h
10	M	41	1	2	Dead	3 days	ED × 1	Anoxyc brain injury/advanced HIV, end-stage renal disease on dyalisis	No	None	African American	Homeless	Unable to obtain	Yes
10	M	41	1	2	Dead	3 days	ICU × 1		No	None	African American	Homeless	Unable to obtain	Yes
11	F	69	10	2	Dead	2h	ICU × 2	Shock/metastatic hepatocellular Ca	Yes	Buddhist	Asian	24 h home care	Full code	No
12	F	80	12	3	Dead	16 h	ICU × 3	Aspiration pneumonia/severe malnutrition, stage 4 decubitus	Yes	None	Caucasian	24 h home care	Full code	Yes
12	F	80	12	3	Dead	0.5 h	ICU × 3	Aspiration pneumonia/severe malnutrition, stage 4 decubitus	Yes	None	Caucasian	Bed-bound	Full code	Yes
13	M	57	1	2	Dead	12.5h	ICU × 2	Acute pancreatis, septic shock	No	Catholic	Caucasian	IADL+	Full code	Yes
14	M	60	29	2	Dead	53h	CCU × 1	Septic shock	Yes	Catholic	Hispanic	Independent living	Full code	Yes
14	M	60	29	2	Dead	53h	ICU × 1	Septic shock	Yes	Catholic	Hispanic	Independent living	Full code	Yes
15	M	46	20	2	Dead	10 days	CCU × 1	Septic shock/ End stage AIDS	Yes	Catholic	Hispanic	Independent living	Full code	Yes
15	M	46	20	2	Dead	10 days	ICU × 1	Septic shock/ End stage AIDS	Yes	Catholic	Hispanic	Independent living	Full code	Yes
16	M	55	1	2	Dead	8 h	RAD × 1	Retroperitoneal bleed/ Cerebral palsy	Yes	Catholic	Hispanic	Bedbound	Unable to obtain	Yes
16	M	55	1	2	Dead	8 h	ICU × 1	Retroperitoneal bleed/ Cerebral palsy	Yes	Catholic	Hispanic	Bedbound	Unable to obtain	Yes
17	M	98	2	3	Dead	6 h	CCU × 2	Septic shock	Yes	None	Caucasian	24 h home care	Full code	No
17	M	98	2	3	Dead	4.5 h	ICU × 1	Septic shock	Yes	None	Caucasian	multiple falls	Full code	No
18	M	75	37	2	Dead	1.25 h	ICU × 2	Septic shock/Profound debilitation with multiple medical problems	Yes	Catholic	Caucasian	SNF resident,	N/A	No
18	M	75	37	2	Dead	1.25 h	ICU × 2		Yes	Catholic	Caucasian	Bed-bound	N/A	No
19	F	46	3	2	Dead	2 h	GMF × 1 CCU × 1	Septic shock	Yes	Jehovah	African American	Independent living	Full code	Yes
20	F	77	6	2	Dead	81days	GMF × 1 CCU × 1	ARDS, Septic shock/ Profound debilitation, stage IV decubitus ulcer	Yes	Catholic	African American	SNFresident,	Full code	No
20	F	77	6	2	Dead	81days	GMF × 1 CCU × 1		Yes	Catholic	African American	bed-bound	Full code	No
21	F	56	1	7	Dead	CRA 1: 9 days	RAD × 1	Septic shock/Profound debilitationwith multiple medical problems	Yes	Catholic	African American	SNFresident,	Full code	Yes
						CRA 2: 19 h	ICU × 6					Bedbound
						CRA 3: 6 h
						CRA 4: 5 h
						CRA 5: 2 h
						CRA 6: 0.5 h
22	F	86	9	2	Dead	46 h	ICU × 2	Septic shock/ Profound debilitation with multiple medical problems	Yes	None	Asian	SNF resident	Unable to obtain	Yes
22	F	86	9	2	Dead	46 h	ICU × 2		Yes	None	Asian	Bedbound	Unable to obtain	Yes

Abbreviations: CRA, cardiorespiratory arrest; F, female; IAL, instrumental activities of daily living; ICU, intensive care unit; CCU, coronary care unit, ED, emergency department; M, male; N/K, not known; RAD, radiology; GMF, general medical floor; PCP, primary care physician; SNF, skilled nursing facility.

Majority (75%) of the multicoding patients had a primary care physician (PCP) involved in their inpatient care during hospital stay when the code happened. Advance directives were discussed on admission in 72.7% of the cases (unable to have discussion in 22.7% of the cases). Poor prognosis has been addressed in the chart in 54% of the cases. The family was contacted and directly involved in decision to continue CPR efforts in 40.1% of the cases. Continued aggressive resuscitation efforts on a patient after survival of the first code were taken based on physician’s assessment in 59.9% of the cases. Among all patients who survived CPR but died during the same hospital stay (27 patients), we found 5 (18.5%) patients had signed DNR.

Discussion

Between 70% and 90% of intensive care unit patients die after a decision has been made to withhold or withdraw life support.^8,11 This percentage has been increasing over the past several years,wues⁷ and the most common reason for withholding or withdrawing treatment is a perception that the patient has a poor prognosis.²¹ Still, a terminally ill patient with a grave prognosis who did not define the limitations to her or his care in case of a cardiac arrest often ends up undergoing continued attempts of CPR regardless of the expected outcome. Although the majority of care providers will agree that resuscitative measures on terminally ill patients can, at best, return them to the dying state and may be highly futile,²⁸ there are numerous reasons why withholding the CPR in a dying patient can be difficult. There are multiple legal and ethical complexities involved including questionable subjectivity of the concept of “terminal condition” and “poor prognosis” as, short of brain death, there are no criteria or rules to which clinicians can appeal to justify decisions to refuse life support at least when those treatments hold even a small chance of achieving the patient’s goals.²⁹

In this retrospective analysis, we tried to achieve 2 goals: (1) to address the concept of futility and help define futility criteria based on the evidence collected in a community hospital and (2) to discuss and recognize the reasons for insufficiently successful recognition of futility in community hospital settings.

According to 1-year data, 22.4% of the patients represent 42.2% of all hospital codes. Of these patients, 95.5% died and 1 patient who survived to hospital discharge had severe neurological impairment consistent with highly unfavorable outcome. Comparing the overall survival to the end-of-hospital stay among all patients who coded with survival to the end-of-hospital stay among patients who coded for the second time, we found that mortality rate is significantly higher when the patient gets a second CRA. This is one of the strong indicators of futility of continued aggressive resuscitation strategy in this subpopulation of patients. If the futility of further resuscitation efforts was recognized after the first CPR, 26% of all codes could have been avoided. Such decrease in the number of codes would contribute not only to more appropriate care delivered to a dying patient (less harm done and comfort care or hospice care provided) but also decrease unnecessary hospital costs. Expanding our analysis from the group of multicoded patients to the group of patients who survived the resuscitation but died during the same hospital stay, we can compare how many of terminally ill patients who survived resuscitation actually was assigned DNR after the code. Five patients who survived the code were assigned DNR right after, making 18.5% of patients with poor prognosis being assigned DNR after the code which sheds slightly different light showing that certain number of unnecessary codes have been avoided but still leaving us with absolute majority of patients with continued aggressive resuscitation approach.

The majority of patients who ended up being resuscitated multiple times were actually good candidates for appropriate assessment of goals of care in a population with severe, chronic underlying disease: 61% of these patients required significant living assistance prior to hospitalization while more than two-thirds of these patients requiring assistance was actually bedbound. Of the multicoding patients, 77% did not have an arrest within the first 24 hours of hospitalization and vast majority (75%) had their primary care private medical attending involved in their care. Yet, these patients were resuscitated 2.7 times on average and all of them had unfavorable outcomes.

When analyzing the reasons for continuation of aggressive resuscitation efforts despite expected poor prognosis, we first looked for the evidence of medical team being aware of poor prognosis. In 54.4% of the cases, there is a written evidence of patients’ poor prognosis assessed by the attending or house staff. Looking back into the reasons for continuing the aggressive resuscitation approach, we find that the family or health care proxy were actively involved and requested attempts at resuscitation in 40% of the cases. It is clear that there are many factors that contribute to family’s or surrogate’s inability to consent to a DNR order including social background, religion, being unprepared for the approaching death of their loved one as well as effectiveness of physician communication. Yet, looking back into our data, we find that all patients who had family involved in the decision to continue resuscitation efforts actually also had a PCP actively involved in patient’s care during the hospitalization when CRA occurred, which brings us to the conclusion that a PCP should take more proactive role in futility assessment and emphasize early and effective communication with the patient and his family. Almost two-thirds of the patients had no input from surrogate or family and futile attempts were continued due to patient’s wish or inability to discuss DNR. Here too, we recognize the need for an attending physician and his team to recognize and act on futility. This can be done as we continue to educate physicians about futility assessment and have this activity incorporated in daily management of hospitalized patients. In addition, it is important to continue attempts to set and further validate clinical prediction rules^30,31 that could use information known at the time of hospital admission and which can possibly identify patients who have little possibility of benefitting from CPR.

Conclusion

Patients who survived CRA after successful CPR, but whose hospital course led to another arrest, have high mortality during the same hospitalization and repeated aggressive resuscitation is often highly futile. If not previously done, objective and protocolized approach with attempts to address, discuss in person, and document the futility assessment is necessary. Immediate multidisciplinary team approach , besides physician who provides the care, may consist of palliative care team, chaplain or spiritual advisor, social worker, patient advocate, and other facilitators who have not been directly involved in providing patient care. This approach, along with understanding that good and devoted communication with patient and patient’s loved ones is sine qua non, should lead to decreased utilization of medically futile interventions and, consequently, led to better, more efficient, and less expensive health care.

Footnotes

Acknowledgments

We would like to thank Cabrini Medical Center for over 100 years of providing great medical care to the residents of New York City and for giving us an amazing opportunity to learn and practice up to date medicine in urban settings. Cabrini Medical Center has closed due to financial difficulties in early 2008, and one of the goals of this report, published several years after the hospital closure, was to address the futility assessment as one of the concepts that, managed differently, could have lead to better financial management of the hospital.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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