October 19, 2017

What Do You Want to Watch? Weather, Sports, Movies…CPR?

By

Distinction must be made between “bad” and “good” CPR.

The first commercially licensed American television channel, station WRGB, began broadcasting on July 2, 1928. Since then, the number of TV channels in the U.S. has ballooned to almost 2,000. There are all kinds of TV channels: weather channels, sports channels, movie channels, and more. But there is no cardiopulmonary resucitation (CPR) channel – yet.

Why would we need a CPR channel in America? Because America is in the midst of an epidemic of futile CPR. Because patients and families who call for uncalled-for CPR very often don’t know for what they are calling. Because there is good CPR and there is bad CPR: CPR that can help and CPR that can harm.

Good CPR is literally livesaving. Early advocates of CPR designed it to save “the heart too good to die.” CPR is a coordinated sequence of procedures that can rescue patients whose lives are unexpectedly threatened. CPR can rescue them from the clutches of death and return them to life. Good CPR does not always have a happy ending, but good CPR is good because it offers the chance of a happy ending.

Bad CPR is CPR on patients with hearts too bad to live, and it is bad because it offers no chance of a happy ending. Bad CPR attempts to rescue patients at the end of their lives who have been approaching death for some time. There is no hope of rescuing them from death, because dying is already part of their lives – they are simply beyond the reach of a CPR rescue.

How does bad CPR end? In a number of bad ways, all of them grim:

  1. Dead: All of the patient is taken, all at once.
  2. Mostly dead: Most of the patient is taken, except for those parts being defended by the rearguard action of machines and medications.
  3. Half dead: The patient enters a comatose neurological netherworld.
     

But how do you tell good CPR from bad? You can’t always, but you can mostly. Bad CPR ends in certain death in certain groups: patients with heart muscle so weakened that it is exhausted just by normal beating, patients with lungs so disfigured that even doing nothing is difficult, patients with cancer so extensive that vast swaths of their bodies are malignant, and patients so frail that gravity has become a disease. So why would anyone want bad CPR? Simple: they don’t know or won’t accept it is bad. Either they haven’t been told it’s bad, or when they are told, they can’t or won’t believe it.

Not being told by physicians happens in two ways. The passive version is unspoken; CPR is not mentioned. The active version involves phrases such as “would you like us to do CPR on your mother?”

Both versions want to avoid the topic of death, the first by ignoring CPR as worthy of discussion, the second by misrepresenting CPR as a worthy option. In both cases, the physician refuses to acknowledge death as an outcome. Physicians who avoid conversions about death just don’t, can’t, or won’t talk about it.

But what about families who are told CPR is bad, but still insist on it? Most do it because they won’t accept that it’s bad, so if talking can’t always persuade them, what can?

Well, apparently CPR videos can persuade many. A recent article in The Journal of Hospital Medicine reports a significant change of mind about choosing CPR and intubation after patients viewed an “informational video:”

http://www.journalofhospitalmedicine.com/jhospmed/article/145134/hospital-medicine/randomized-controlled-trial-cpr-decision-support-video.

The results were striking: less than half chose CPR after viewing the video (a kind of CPR infomercial) compared with those not shown the video. Similarly, three times as many chose a “DNR/DNI” (do not resuscitate/do not intubate) status as the non-viewers. Impressive news, but it’s not really new news, as similar studies have reported similar findings for the last 10 years.

So if the published data supports a “WCPR” channel, why don’t we have one? Perhaps because of what is playing on all the other TV channels.

In what may be the only article ever published in the New England Journal of Medicine wherein all the research was done in front of a television, the authors of the 1996 article Cardiopulmonary Resuscitation on Television watched a whole year’s worth of the then-popular medical TV shows “ER,” “Chicago Hope,” and “Rescue 911.” This was published 21 years ago, before “I read it on the Internet” replaced “I saw it on TV” as the ultimate arbiter of truth.

The study reported a number of findings. First, the TV CPR depictions were unrealistically depicted. CPR was effectively “airbrushed” – no needles anxiously probing for veins to cannulate, no laryngoscopes desperately searching for vocal cords to intubate, no fingers frantically handling ampules and syringes. There was no mucus, no vomit, no blood. Second, an astounding 75 percent of TV patients survived CPR, which is significantly greater than the survival rates in even in the most ideal real-life situations: http://www.nejm.org/doi/full/10.1056/NEJM199606133342406

Those who have participated in CPRs know that no amount of makeup can mimic the color that replaces the living color of a patient’s face when CPR fails. And no directors or actors can ever fully accurately recreate the scene of the hushed voices and the flushed faces after the last words of a futile CPR are spoken: “let’s call it.”

The cost of failed CPR is devastating to all – the patient, their loved ones, and their CPR caregivers. Increasingly, CPR is being recognized as a cause of post-traumatic stress disorder (PTSD) in those who participate in futile CPRs.  CPR is a punishing procedure. Perhaps even more punishing is the dread of the bedside nurses who care daily for patients who they know in their hearts will not survive CPR. They know that calling a “code blue” for these patients will be fatal. 

There are several states with “futile care” laws, through which various combinations of physician opinions can override the patient’s or family’s wish for “futile” CPR. But in most states, futility isn’t illegal, so some doctors have devised dilatory practices to partially “honor” insistence for bad CPR. There is the infamous CPR pantomime known as the “slow code,” which isn’t really CPR. There is the ineffective “medications but no compressions” CPR, which isn’t really CPR. Finally, there is the guaranteed-to-fail “resuscitation without intubation,” which isn’t even resuscitation. Faced with bad CPR, some physicians would rather fake it than take it head-on.

So, do we need CPR videos? It would seem that the facts and the literature indicate that we do. But do we need “CPR TV?” Well, maybe we just need more CPR talk radio, because the CPR channels in most doctors’ offices show only silent movies. Successful videos reflect mostly unattempted conversations about futile CPR. We need early and frequent conversations about dying, before it the lives of the sick and fear replaces reason. Death should never be a surprise ending to a fatal illness.

We need to talk and act like dying is just as much a part of life as birth is. Being a baby and being a corpse are the bookends of all lives. For those with “hearts too good to die,” we should do CPR with all our medical might. It is the purpose of medicine to prevent preventable death. It is also the purpose of medicine to prevent preventable suffering. When death is inevitable, we should attempt with all our medical might to comfort those last breaths of our patients and the loved ones who surround them.

Futile CPR – CPR medically preordained to fail – is worthless punishment that leaves behind worthless suffering. No one should be punished for dying, but some still are. CPR videos are already playing in a few hospitals, and who knows, “The CPR Channel” may be next.

But if CPR TV goes on the air, it needs to be a talk show.

Michael A. Salvatore, MD, FACP, CHCQM

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

This email address is being protected from spambots. You need JavaScript enabled to view it.