Correspondence
Prognosis and Cardiopulmonary Resuscitation in Elderly Patients
N Engl J Med 1994; 331:479-480August 18, 1994
- Article
To the Editor:
Dr. Murphy and his colleagues (Feb. 24 issue)1 substantiate the fact that elderly patients both understand the implications of prognostic information concerning the results of cardiopulmonary resuscitation (CPR) and are willing to alter their preferences in response to it. Such studies support the position that we can eliminate the presumption of consent for CPR and instead allow individual patients to make their own informed choices.
However, we suggest that the pie chart shown in their Figure 1 should be modified to deal forthrightly with the risk of neurologic disability for patients who do survive resuscitation. In our own recent review2 of the pertinent literature,3-5 we concluded, “About one-half of CPR survivors will have permanent neurologic disability.” Attempting to cope with such an impairment may be viewed by some as even worse than death. A clear articulation of these data must be part of the process of fully informed decision making.
5 ReferencesAllan S. Jaffe, M.D.
William M. Landau, M.D.
Washington University School of Medicine, St. Louis, MO 631101
Murphy DJ ,Burrows D ,Santilli S , et al. The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994;330:545-549
Full Text | Web of Science | Medline2
Jaffe AS ,Landau WM . Death after death: the presumption of informed consent for cardiopulmonary resuscitation -- ethical paradox and clinical conundrum. Neurology 1993;43:2173-2178
Web of Science | Medline3
Roine RO ,Kajaste S ,Kaste M . Neuropsychological sequelae of cardiac arrest. JAMA 1993;269:237-242
CrossRef | Web of Science | Medline4
Earnest MP ,Yarnell PR ,Merrill SL ,Knapp GL . Long-term survival and neurologic status after resuscitation from out-of-hospital cardiac arrest. Neurology 1980;30:1298-1302
Web of Science | Medline5
Longstreth WT Jr ,Inui TS ,Cobb LA ,Copass MK . Neurologic recovery after out-of-hospital cardiac arrest. Ann Intern Med 1983;98:588-592
Web of Science | Medline
To the Editor:
Murphy and colleagues have clearly demonstrated that knowledge of the probable outcome after CPR has an important influence on patients' preferences. If doctors other than those with a special interest in the subject are to discuss CPR with their patients, however, then they require at least an accurate knowledge of the outcome in different circumstances. There is at present little published work showing that this knowledge exists.
We recently surveyed the medical staff at a teaching hospital in the United States and at a teaching and associated district hospital in the United Kingdom1 and asked the respondents to estimate survival to discharge after CPR in general acute care hospitals. We received replies from 86 American and 108 British doctors. Only 29 doctors in the United Kingdom (27 percent) and 28 of those in the United States (33 percent) gave an answer between 10 and 17 percent, the range accepted by Murphy and colleagues for survival after attempted resuscitation during hospitalization with an acute illness. Of all doctors surveyed, 35 (18 percent) estimated that survival was less than 10 percent and 102 (53 percent) that it was above 17 percent.
Most of the doctors we surveyed overestimated the potential for survival after CPR. It is essential that training programs in CPR include accurate information on outcomes.
1 ReferencesAdrian Wagg, M.B.
Northwick Park Hospital, Harrow, Middlesex HA1 3UJ, United KingdomKevin Stewart, M.B.
Newham General Hospital, Plaistow, London E13 8RU, United KingdomMark Kinirons, M.B.
Vanderbilt University Medical Center, Nashville, TN 37232To the Editor:
There may be a difference between the outpatient setting referred to in the study by Murphy et al. and the hospital environment in which patients are acutely ill and perhaps cognitively impaired, and where priorities may differ. Our research from two Dublin teaching hospitals1 suggests a reluctance among physicians working with geriatric and general medical patients to raise the question of resuscitation status with their patients.
Of 165 patients, consultant physicians thought it appropriate to discuss CPR with only 12 percent but said they would raise the matter with family members in 44 percent of the cases. The nursing staff believed the issue should be raised with patients in 35 percent of cases and with family members 85 percent of the time. The reasons given for the reluctance of the medical staff to allow their patients to be confronted with this issue were that the decision was too obvious in the case of trivial illness or that the question of resuscitation status was too threatening to be discussed with the patient, particularly after admission.
1 ReferencesDeclan Lyons, M.R.C.P.
Desmond O'Neill, M.D.
Riona Mulcahy, M.B.
Meath Hospital, Dublin 8, IrelandAuthor/Editor Response
The authors reply:
To the Editor: The survey by Lyons and colleagues in Dublin reflects what we see in hospitals in the United States; only a minority of patients have had discussions about CPR by the time they are hospitalized. We understand why some types of advance directives might not seem appropriate for young, healthy patients. However, discussions about CPR are appropriate for most older patients. These patients rarely feel threatened by such discussions. We often open the conversations by telling the patients that CPR is something we discuss with all our patients. This seems to allay any anxiety the patients may have about such discussions. It works well in the outpatient and inpatient settings.
Dr. Wagg and colleagues remind us that a large percentage of physicians do not have a good understanding of the outcomes of CPR. We are not sure how to correct that deficiency. An approximation of the prognosis may be the best that many physicians can do. We believe this is better than no discussion of outcomes.
Drs. Jaffe and Landau suggest that the discussions with our patients may not have been realistic in presenting the likelihood of permanent neurologic disability. They are probably right. We tended to paint an optimistic picture of life for the survivors of CPR. We agree that many elderly patients would view permanent, substantial neurologic disability as a state worse than death. Our impression is that some patients who said they wanted CPR would have changed their minds if they had known that the chance of permanent neurologic disability was higher than we suggested.
Donald J. Murphy, M.D.
David Burrows, M.D.
Sara Santilli, R.N., M.S.N.
Presbyterian-St. Luke's Medical Center, Denver, CO 80218- Citing Articles (1)
Citing Articles
1
Betty A. Ditillo. (2002) Should There be a Choice for Cardiopulmonary Resuscitation When Death is Expected? Revisiting an Old Idea Whose Time is Yet to Come. Journal of Palliative Medicine 5:1, 107-116
CrossRef
