Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten
Sept. 8, 2004

CONSIDERATIONS REGARDING CARDIAC RESUSCITATION

     There is no more frantic time in a medical setting than when a patient has a cardiac arrest.  The heart stops beating for any one of many possible reasons.  Unless the heart can be restarted, the person dies.  In the 1950’s, it was learned that chest compressions with the heel of the hand over the heart area at about 60 times per minute was able to maintain blood outflow to the body enough to sustain life.  Over the last 50 years, the chest compression procedures have been refined to create programs called Basic Life Support and Advanced Cardiac Life Support.  These two programs are devised and revised by the American Heart Association.  These programs delineate what to do when a person has a cardiac arrest.  The Basic Life Support Program is devised for the general public and the Advanced Cardiac Life Support Program is devised for medical professionals such as ambulance attendants, nurses, physician assistants, nurse practitioners and doctors.  Appropriately applied in a timely manner, these two programs can result in as much as 33% survival for victims of cardiac arrest.  On the average across the country, the likelihood of survival with a resuscitate effort is around 15% but it is 0% with no resuscitative effort.

    The reason for writing this column is to clarify certain considerations regarding the resuscitative procedures.  Recently, a lady with diabetes and kidney failure came to the hospital because of shortness of breath.  The shortness of breath was dealt with by helping her get rid of excess fluid and medications to better control her blood pressure.  She had been diabetic for 20 years and already had two heart attacks with severe heart failure.  She was informed that the kidney function was marginal and that eventually at some point in the future, she might well have to use artificial-kidney treatments in order to remain comfortable and alive.  After considering the alternatives, she elected to decline any dialysis care and she requested that she not be resuscitated if a mortal event were to occur.

     Soon thereafter, the patient collapsed at home while watching television with her family.  Her family immediately called 911 and the ambulance was dispatched to her home within six minutes.  The ambulance personnel found her to be in cardiac arrest and the family overrode the patient’s wishes saying that she should be resuscitated.  The resuscitation procedure progressed for almost twenty minutes before an effective heart beat could be re-established.  During this time, her brain received only minimal amounts of blood.  On arrival at the hospital, she had a heart beat and blood pressure but was “brain dead”.  Over the next several days, she remained on a respirator as her family tried to decide their next step.  It is a grotesque consideration for medical personnel to ask the family if the respirator should be turned off because the person no longer has any mental function.  To me, it is a blessing when fate intervenes and the person’s heart stops a second time and cannot be restarted.  At least then both medical staff and family are spared the agony of making a decision to “turn off the respirator”.

The above case is an example of futility.  In a series of over 400 cases of chronically ill hospital patients there were no survivors when a resuscitative effort was made as the person’s heart stopped.  Most of the time medical care had been intensively delivered to these individuals and the ravages of disease finally won out.  Resuscitative procedures at that point serve no purpose.  Many patients anticipate this possibility and sign living wills or other directives stipulating that resuscitative efforts are not to be made in the event of their demise.  Unfortunately, these directives are often overlooked or overruled.

As a general rule if an effective heart beat can be re-established within eight minutes of the time of a cardiac arrest, an otherwise healthy person can return to normal function.  At St. Mary’s Hospital in Pierre there is a display called the Tree of Life.  On this display are the names of over 200 people in the Pierre area alone who have been treated with resuscitative procedures and survived to get out of the hospital alive.  Thus resuscitative procedures do have a place.  Who are those people who can be resuscitated successfully and return to a normal life?

    An example of a successful resuscitation is a 64-yr old rancher who developed chest pain while doing morning chores.  He returned to the house where his wife called 911 and an ambulance was dispatched to his home to bring him to the hospital.  It took almost an hour to get him there and on arrival it was obvious that he was having a heart attack.  He was coherent and able to give meaningful history but he had a cardiac arrest right in front of the medical personnel.  Resuscitative procedures were undertaken within one minute.  An electric shock was applied to his chest and his cardiac rhythm was re-established.  Subsequently, he had the blocked artery in his heart opened and he returned to a normal life.

Five years later he came back to the hospital with almost the same story and had a second cardiac arrest.  Again, fortunately, it occurred in front of medical personnel and an electric shock was able to re-establish his heart rhythm again.  That was five years ago and he remains an active rancher to this time.  He has enjoyed watching his grandchildren grow up and has no disability.  This is the place where cardiac resuscitation pays back huge rewards.

For both the lay public and for medical personnel to realize, if an effective heart beat cannot be re-established within 8 minutes, the likelihood of some brain damage is expected.

    If an effective heart beat cannot be re-established within 30 minutes, there is no realistic expectation that mental function will return at all. Sometimes cardiac function can be re-established late in a resuscitive procedure and the person is placed on a respirator.  It is at those tragic times that families are faced with the horrible decision of when to “turn off the respirator”.  Cardiac resuscitation has its place but it is not a useful step for the late-stage chronically ill individual with multiple medical problems who then has a cardiac arrest.  The likelihood of resuscitation in those situations is very poor and the result of any resuscitation is often a tragedy worse than the patient’s demise might have been.

     As a closing note, all patients who are admitted to a hospital are now asked whether they want to be resuscitated should a mortal event occur.  It is a federal law and patients must make their decision or have their appropriate next of kin make that decision for them.  In my experience, the moment this question is asked is one of the ugliest crunch points during a hospital admission.  A knee jerk reaction is very frequently ”yes” they want to be resuscitated.  It is hard to imagine the cruelty of informing a patient that the resuscitative procedure probably won’t work and may result in a grotesque outcome.  Be that as it may, the question must be asked by federal law.  Patients and family need to aware that this question is coming and take more than a few seconds to snap off an answer.  The healthcare professionals at your local clinic can help in preparing for these unfortunate times and avoiding further tragedy on top of the one that they are already facing.