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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.

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Presentation on theme: "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."— Presentation transcript:

1 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

2 CPR Uniquehigh stakes, life or death, starkUniquehigh stakes, life or death, stark Abruptmust be refused in advanceAbruptmust be refused in advance Standardizedroutine, ACLS protocolStandardizedroutine, ACLS protocol Universalpotential use: everyoneUniversalpotential use: everyone Iconicrepresents promise and misuse of modern technical medical capabilitiesIconicrepresents promise and misuse of modern technical medical capabilities

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4 CPR Decision Making Presumption to treatPresumption to treat No decision=consent to CPRNo decision=consent to CPR Documentation regulatedDocumentation regulated

5 Reasons to Use CPR Benefits > BurdensBenefits > Burdens –Its good to be alive! –Burdens trivial by comparison DesperationDesperation

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7 Reasons to Refuse CPR (consent to DNR) Little empirical data in literatureLittle empirical data in literature Theoretical constructTheoretical construct –Tomlinson T. Brody H. Ethics and Communication in Do-Not-Resuscitate Orders. NEJM (1988) 318:43-6 NYS DNR LawNYS DNR Law SymbolismSymbolism Cynical viewCynical view

8 Reasons to Refuse CPR Tomlinson & Brody No Medical BenefitFutileNo Medical BenefitFutile Poor Quality of Life after CPRCNS damage, life support etcPoor Quality of Life after CPRCNS damage, life support etc Poor Quality of Life before CPRIts NOT good to be alivePoor Quality of Life before CPRIts NOT good to be alive

9 Reasons to Refuse CPR Patient is DyingDying causes cardiac arrest (not other way around)Patient is DyingDying causes cardiac arrest (not other way around) Poor Quality of Life after CPR Clinical determination (+ pt/surrogate)Poor Quality of Life after CPR Clinical determination (+ pt/surrogate) Poor Quality of Life before CPR Patient/surrogate assessmentPoor Quality of Life before CPR Patient/surrogate assessment

10 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:

11 NYS DNR Law 1.the patient has a terminal condition; or 2.the patient is permanently unconscious; or 3.resuscitation would be medically futile; or 4.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.

12 Symbolic Nature of CPR Icon of aggressive careboth good and badIcon of aggressive careboth good and bad –Full code = fighting back –DNR = giving up

13 Symbolic Nature of CPR Patient/Family Attitudedoubtful that patient/family who wish full code really accept reality of fatal illnessPatient/Family Attitudedoubtful that patient/family who wish full code really accept reality of fatal illness Physician/Staff Attitudepresence of DNR order implies desire for less aggressive treatment in other realmsPhysician/Staff Attitudepresence of DNR order implies desire for less aggressive treatment in other realms

14 DNR and non-CPR Care Physician/Staff Attitudepresence of DNR order implies desire for less aggressive treatment in other realmsPhysician/Staff Attitudepresence 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,.Beach MC, Morrison SR, The Effect of Do-Not- Resuscitate Orders on Physician Decision-Making. J Am Geriatr Soc (2002) 50:2057–2061,.

15 DNR and non-CPR Care Beach and Morrison Physician surveyPhysician survey 3 Clinical vignettes3 Clinical vignettes 2 Versions of each2 Versions of each –One with DNR –Other no DNR Sequential treatment decisionsSequential treatment decisions

16 DNR and non-CPR Care Beach and Morrison

17 Reasons to Refuse CPR Cynical Because the physician approaching the patient/family thinks its a good idea and persuades the decision makerBecause the physician approaching the patient/family thinks its a good idea and persuades the decision maker Gory details (break your ribs)Gory details (break your ribs) Often no mention of survival/outcome dataOften no mention of survival/outcome data

18 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.Presumes people make DNR decisions based on probability of poor outcome with CPR. Overlooks high-yield circumstances (relatively good outcomes with CPR):Overlooks high-yield circumstances (relatively good outcomes with CPR): –Witnessed shockable rhythms –CPR in OR –Iatrogenic/procedures

19 Rational Approach Witnessed shockable rhythmsWitnessed shockable rhythms CPR in ORCPR in OR Iatrogenic/proceduresIatrogenic/proceduresChoudhry: LATO order: Limited aggressive therapy;LATO order: Limited aggressive therapy; Intermediate status.Intermediate status. UnwieldyUnwieldy Short Code.

20 Code Duration and Outcome Variety of outcome measuresVariety of outcome measures –Restoration of spontaneous circulation –Survival at 24 hours –Survival to discharge Variety of timeframesVariety of timeframes – 5, 10, 15, 20 min –Ranges (5-10, 11-15, 16-20 etc) –Mean CPR time among survival

21 Short Code Allows patient to avoid outcomes of prolonged codeAllows patient to avoid outcomes of prolonged code Eliminates generalizing DNR to other decisionsEliminates generalizing DNR to other decisions NOT a sham code ( slow code, show code)NOT a sham code ( slow code, show code) NOT a partial code (CPR but DNI)NOT a partial code (CPR but DNI) Go all outbut for less timeGo all outbut for less time No confusion in initiating codeNo confusion in initiating code No confusion in running of codeNo confusion in running of code No confusion in ending codeNo confusion in ending code

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23 Cooper & Cade 1997

24 Millard Gates 12/06 – 12/07

25 Survived Procedure

26 Survived 24 Hours

27 Survived to Discharge


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