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Gettysburg Medical News
The Clinical View
By P.E. Hoffsten, MD
23 January 2008

CPR-II:  THE DOWN SIDE

                        Last week the column dealt with cardiopulmonary resuscitation (CPR) and described some basic considerations.  It was explained that CPR is an orchestrated sequence of medical steps designed to restart a person’s heart when it has suddenly and unexpectedly stopped.  An example of appropriate use of CPR is described below.

            The gentleman was a 68 year old rancher who had not had medical attention in years.  He was as robust and stout a cowboy as you would ever see.  But he hadn’t paid attention his blood pressure or his cholesterol and his blood sugars tended a little bit high and he still smoked a pack of cigarettes a day.  He was a set-up just waiting for the heart attack to occur.  He came to the emergency room because his wife insisted.  He had been having chest pain for several days and attributed it to “indigestion”.  On arrival in the emergency room, electrocardiogram looked normal and as far as he was concerned that is all he needed.  He wanted to go home.  The doctor in the emergency room noted that the patient’s blood pressure was somewhat elevated at 180/110 and suggested that he be admitted to the hospital in light of his history and the very high blood pressure.  This cowboy was very adamant that he didn’t need to be in the hospital and he wasn’t staying.  Unfortunately, his wife disagreed and the two began to discuss the matter in somewhat heated terms.  It was at this point, that he developed chest pain again but then something very dramatic happened. 

            The gentleman was sitting on the side of the hospital cart and in mid sentence slumped backward onto the cart.  Medical personnel had left the room while the patient and his wife were discussing the matter.  The wife immediately called for help and the nurse came into the room and noted on the cardiac monitor that the patient had a cardiac arrest.  The nurse pushed the “Code Blue Button” and within 2 minutes a respiratory therapist arrived, a physician arrived, two more nurses arrived and full cardiopulmonary  resuscitative procedure was carried out.  A standard DC electrical cardioversion was carried out very quickly within that first two minutes and the patient’s cardiac rhythm was re-established

.           Needless to say, the argument about hospitalization ended at that point and he was eventually transferred to a heart hospital where a 4-vessel coronary artery bypass was carried out.  That was 1988 and he is still alive today, although somewhat more attentive to his health considerations than he was before.  This is a clear example of a very appropriate application of cardiopulmonary resuscitation.  This gentleman would have had a mortal outcome without the cardiopulmonary resuscitation that was done.

            But there are times when cardiopulmonary resuscitation is very inappropriate as illustrated in the case below.

            The lady was a very frail 110 pounds after losing 30 pounds over the previous six months due to the slow progression of a cancer of the lung.  She was short of breath at rest, on oxygen, and on substantial doses of narcotics to prevent bone pain.  Although frail, she was managing activities of daily living at home by herself.  She lived 14 miles from the city limits by herself. 

            One of her daughters came to visit and was staying with her mother.  While enjoying their morning coffee the patient said that she just didn’t feel right.  She got up to walk over to the couch to lie down but never made it.  Halfway to the couch, the lady collapsed and fell to the floor unconscious.  Her daughter tried to revive her for an unknown short period of time and then called for an ambulance. The ambulance arrived twelve minutes after the call was received.  A realistic estimate of the time from the collapse until first medical attention arrived would be 15 minutes.  The emergency medical technicians inquired from the daughter as to what had happened.  The daughter asked the emergency medical technicians to please do everything possible.  According to the emergency medical technician procedural code, CPR was started.  It was seen that the patient was in ventricular fibrillation and cardiopulmonary resuscitation was started.  The daughter recalls the procedure as her mother‘s chest was compressed.  Subsequently, an electrocardioversion was carried out and a cardiac rhythm was re-established.  The lady was taken to the hospital and placed on life support with intubation and artificial respiration. Her heart rhythm remained stable.  Over the next two weeks, the patient would intermittently regain consciousness, obviously in severe pain but not recognizing anyone or recognizing her situation. Several family members had gathered but could not agree on the level of care that the patient should receive.  The lady had not designated a guardian or expressed her wish regarding end-of-life considerations.  A feeding tube was eventually placed to provide nutrition but the patient expired after about two weeks.

            The daughter who was with her at the time of the patient’s collapse came to see me several  weeks later.  She said that she had gone through her mother’s papers and found a living will stating that the patient had not given to anybody or even let them know that it existed.  The living will clearly stated that the patient wished to have no life sustaining steps taken if she were to have a mortal outcome from her lung cancer.  Two weeks of dehumanizing family fractionating treatment might have been avoided.  The daughter clearly expressed her regret about having ever called the ambulance to begin with. 

            This is an example of a situation where cardiopulmonary resuscitation is mandated on the EMT’s when there is no specific directive not to do so.  In order to deal with a situation where unwanted CPR is administered, a new set of rules was legislated several years ago.  This set of rules is called the “Comfort One DNR” rules.  It basically involves the use of a bracelet clearly stating that the person does not wish to have cardiopulmonary resuscitation should they meet a mortal outcome.  These bracelets are appropriate for individuals who have terminal illnesses from which they can not be expected to recover.  If emergency medical technicians happen upon a person who has collapsed and has one of these bracelets, they may allow the person to have a dignified death and avoid the horrible ordeal of days or weeks of inappropriate and futile care.  These bracelets can be obtained by writing to Emergency Medical Services, 118 West Capital Avenue, Pierre, South Dakota 57501. Information can be obtained by calling 605-773-4031.

            Discussions regarding end-of-life considerations are never comfortable.  They often involve tears and gut wrenching considerations when loved ones get involved in this type of discussion.  As hard as these discussions seem to be, they are important for family members who are left behind with no direction when the future is not discussed.  It is my opinion, that we owe it to our loved ones to let them know our wishes and give them direction prior to the crisis that can occur.

This and other columns available at www.macpierre.com.