A cardiac arrest is by definition the end of life.  In the 1950’s, it was discovered that the use of an electrical shock or even a thump with a fist on the person’s chest can sometimes re-establish a heartbeat and the person’s life be re-established.  Now the Americal Heart Association has devised a set of steps and procedures to use when a person encounters a cardiac arrest.    Sometimes the person’s life can be saved.  Many times it cannot.

 When a person enters a hospital there are a set of federal regulations and procedures that need to be followed.  One of the questions that are required to be asked is, “If your heart should happen to stop, would you like to be resuscitated?”  Entering a hospital is anxiety producing enough.  As if the poor patient didn’t have enough to worry about, now they get asked a brutal question like this.  Begging everyone’s pardon, it is a federal regulation and has to be recorded in the hospital chart.  Most people haven’t thought about it and the question takes them by surprise.  The following are the considerations when answering this question.

 First, it needs to be understood that cardiac resuscitation is a procedure.  It has a set of medical rules on how to do it every bit the same as the rules for doing an appendectomy or treating pneumonia or treating diabetes.  The first consideration in answering the question above is whether the procedure is warranted.

 In the bad old days before the above federal regulation was put in place, I was called to a cardiac arrest in the room of a gentleman who was 94 years old.  He had long suffered from cancer of the prostate and had been admitted to the hospital for care and comfort for the terminal stages of his illness.  Nature took its course and he passed away as expected.  Unfortunately, the gentleman’s passing was witnessed  by a student nurse.  Not knowing better she pushed the cardiac code button.  There arrived 15 people in less than one minute and a cardiac resuscitation was undertaken.  On my arrival, I recognized that the procedure was not only going to be ineffective but inappropriate compared to the gentleman’s wishes.

 Thus, fact #1 to consider.  In a series of more than 250 cases of cardiac arrest occurring in patients who were medically very ill with pneumonias or other infectious or degenerative disease, the likelihood of effectively resuscitating them in the terminal stages of their illness was 0.  This study was published in the past ten years with modern techniques and points out the utility of trying to resuscitate the individual with end stage acute and chronic disease.

 In another case, a 45 year old woman had a form of cancer called lymphoma.  This type of cancer can often be completely cured although the person will be very ill from the disease and also from the treatment.  She came to the hospital with a very high fever from an infection in her lungs.  Soon after admission she too had a cardiac arrest and resuscitated efforts were undertaken.  The efforts were successful and eventually her lymphoma was effectively treated She is alive and doing well fourteen years later.

 The difference between the above two cases is that the 45 year old lady had some hope of recovery and the expectation of a good quality of life after that recovery.  The 94 year old gentleman had been through chemotherapy that was unsuccessful, he was in substantial pain constantly, and he had no hope of recovery.  Resuscitation when there is hope of recovery of meaningful, quality of life is indicated.  It may or may not be successful but it is an indicated step.  Resuscitation attempts in people who are miserable with no hope of recovery in the end stages of their life are not indicated.

 In another example, a 63 year old gentleman came to the hospital because he had chest pain.  He was initially evaluated and found to be having a heart attack.  On the way to the intensive care unit, he had a cardiac arrest from which he was successfully resuscitated.  It is now nine years later and he is leading a normal life.

 Approximately one-third of in hospital unexpected cardiac arrests can be resuscitated and leave the hospital able to return to their normal life.  If a cardiac arrest occurs outside the hospital, only 15% of people survive under the best of circumstances.

 The last consideration has to do with how long resuscitative efforts should be made.  If a person can be revived within four minutes from the time of the arrest, normal function of the brain can be expected.  If resuscitation is not achieved until after eight minutes from the time of arrest, there very frequently is some irreversible brain damage.  If the person can not be resuscitated within a half an hour at the time of the cardiac arrest, permanent irreversible brain damage is an expectation.  The person is often on a respirator and “brain dead”.  Families are then faced with the grotesque decision of whether to “turn off the respirator”.  Healthcare providers need to be very, very careful in making the momentous decisions on whether to start resuscitative efforts and how long to continue them.  The decisions need to be made with respect to the patient’s long-term prognosis, the patient’s personal desires, the family’s expectations, the likelihood of success in the resuscitative effort and the post resuscitative state of the patient.

 Many patients now are arranging for “Living Wills” or “Advanced Directives” that express their desires in regard to resuscitative efforts.  These provide the primary directive on what the healthcare providers should do when faced with this situation of a cardiac arrest.

 Hoffsten’s First Law states, “Nothing in medicine is ever easy”.  The second law is, “Nothing in medicine is ever simple”.  Never were these two laws more applicable than when considering a cardiac arrest.