CPR not always appropriate for senior patients
When older hospitalised patients need revival by CPR, more than half are likely to die before they are discharged, according to a new study.
The odds of surviving long enough to leave the hospital drop with increasing age, the researchers found. And those who are discharged may be left with functional deficits.
"Most patients that I talk to are surprised about how few patients actually survive to hospital discharge," Dr William Ehlenbach told Reuters Health.
"I think that if you have a loved one, an older person who is in the hospital, I think having a realistic understanding of CPR and outcomes is really important," said Ehlenbach, a specialist in pulmonary and critical care at the University of Wisconsin, who was not involved in the study.
CPR may not be appropriate
Cardiopulmonary Resuscitation (CPR) is the standard treatment for cardiac arrest worldwide, but physicians tend not to accurately predict the outcome, even after reading detailed patient information, the study's authors write in the journal Age and Aging.
"With increasing age of in-hospital patients, physicians are frequently confronted with the question if resuscitation is a medically appropriate and ethically acceptable treatment for an older patient," they note.
The study was led by Dr Dionne Frijns, a geriatric medicine researcher at Diakonessenhuis hospital in Utrecht, the Netherlands.
For doctors and patients to make informed choices about resuscitation in the hospital, better information about the consequences is needed, they say.
The researchers systematically reviewed previous studies that investigated the survival rates of patients undergoing in-hospital CPR. They included a total of 29 studies that involved a total of 417 190 patients over the age of 70.
The researchers found that about 40% of the patients had successful CPR, or 'return of spontaneous circulation,' but more than half of those patients ultimately died in the hospital.
For patients aged 70 to 79, the rate of survival to discharge was about 19%, for patients aged 80 to 89, the rate was 15% and less than 12% of patients over the age of 90 were eventually discharged.
Focus on pre-arrest factors
Only four of the studies looked at the quality of life of CPR survivors who left the hospital. Two studies indicated that patients maintained levels of independence similar to what they had before CPR, but the other two found that just 20 to 40% of survivors were able to function independently outside of the hospital.
"Even though the survival rates appear to be low in older people in general . . . there could be certain elderly patients for whom CPR is a worthwhile intervention," the authors write. "Future research should focus on pre-arrest factors" that could predict which patients most likely to benefit from CPR, they conclude.
Ehlenbach thinks that understanding the probabilities of survival after CPR have the potential to affect the decisions that people make at a very difficult time.
He points out that patients who are successfully resuscitated may spend extra days or weeks in the hospital, but still not survive.
"For those patients what we're really doing is prolonging their death rather than restoring health or restoring life," he said.
For those who survive with functional deficits, Ehlenbach added, "We just don't have a good base of studies to help us estimate what that likelihood of a new deficit or neurologic disability is. There really haven't been a tremendous number of studies that look at functional status."
But, Ehlenbach said, patients he talks to are very interested in knowing if they'll be able to function independently if they ever need CPR.
"Certainly what I hear from patients in my practice as a critical care physician, is that patients – particularly older patients – are very much thinking about survival," he said. "But not only thinking about survival, they're really thinking very much about functional status and so that's important."
Ehlenbach recommends that everyone, especially older adults with advanced chronic illness, talk to their loved ones about their wishes regarding resuscitation, including advanced directive documents, living wills and health care power of attorney.
"Many of those decisions are made during an acute illness or catastrophic illness and many times the individual themself isn't making that decision," he said. "They may be too sick at that moment so often times it's loved ones – spouses and children – who are actually having those conversations with physicians."
Ehlenbach added that for the past two decades there's been a lot of emphasis on encouraging physicians and other providers to talk about these issues with all patients when they are hospitalized, but that those conversations still don't take place as often as they should.
"I think patients need to feel empowered to bring up these conversations, particularly when they are being admitted to hospital," he said. "So if their physician isn't the one initiating the conversation, the patients should really feel empowered to make sure that their wishes are known – regardless of what those wishes are."
Image: Medical personnel doing CPR from Shutterstock