Survival in Hospital Cardiac Arrest - Challenges for Hospitalists
The September 2010 publication of “The Hospitalist” reviews the overall survival rates for cardiac arrest patients.
This article reports that patients frequently have unrealistic expectations and overestimate their chances of survival. Patients predict post-arrest CPR survival at 64%, while the rate is 17%. Most important is that in nearly half of the patients who initially expressed the desire for CPR, once they were informed of the actual estimates, they changed their minds and code status was changed.
It is difficult for many hospitalists to discuss DNR orders with patients. There is not a trusting relationship formed over time. Therefore it is often difficult to broach the subject with patient's or their surrogate decision makers.
For an in-depth and legitimate conversation leading to an informed consent to take place there must be a serious and comprehensive discussion of the patient's history and resuscitation statistics to the degree that they are reliable and clinically significant. The article notes that the “presence of hepatic insufficiency, acute stroke, immunodeficiency, renal failure, or dialysis were associated with lower survival rates.” The authors also note that survival rates are lower with metastatic disease and other malignancies.
Age and a history from prior skilled nursing facilities were associated with poorer survival rates and racial statistics also play a part in survival rates. This article discusses a study that reviewed the medical records of 433,985 Medicare patients 65 years and older who underwent in-hospital CPR. Patients 85 and older had a 6% chance of surviving hospital discharge. This, however, is a statistic and cannot be provided to patients without a detailed discussion of their specific medical condition. Survival rates tend to be lower in patients who are black/nonwhite. Blacks and nonwhites are reported to use CPR at a higher rate but with lower survival rates.
Most importantly, any discussion must include a description of the probable quality of life with post arrest survival. The authors take note that in post resuscitation survivors, in 86% of patients with pre-arrest cognitive abilities remain the same on discharge. Please note that a boilerplate prediction of survival will not pass legal muster.
A Cautionary Note: We should also be alert to the fact that some patients may tend to have a grimmer perspective of survival because of a diagnosis of a malignancy, albeit the cancer is in early stages and not immediately life-threatening. Fear of “cancer” does frighten patients to the point where they will opt for a DNR order prematurely when it may result in an unnecessary early death. Hospitalists, therefore, must include a detailed description of cancer staging, and in such instances take a wait and see position to allow the discussion to continue with the patient’s primary treating physician.
Bernard W. Freedman, J.D.,M.P.H. is an attorney at law and an active member of the California State Bar since 1976. (State Bar number 70888). He has specialized in medical legal law and acted as consultant in clinical bioethics and...