Sunday, September 15, 2013

Should CPR Be the Default Treatment for All Cardiac Arrests?

Slow, creeping changes gradually transform the structure of our health care system—sometimes for the better, sometimes not. Creep[1] is a word describing a complex phenomenon:
  • The gradual and unmanaged addition of additional treatments/procedures/features in a practice/mission/product.

In this article, we will examine "medical creep." Medical creep[3] happens when doctors practice "outside the box," performing procedures or prescribing treatments for patients in the absence of clear evidence that patients will benefit. Cardiopulmonary resuscitation (CPR),[16] the procedure used to treat patients who suffer cardiac arrest, is an example of medical creep.


How Was Cardiac Arrest Treated before CPR Invention?


Before 1960, the only way to treat cardiac arrest required surgical opening of the chest cavity and manual cardiac massage, whereby the surgeon holds the heart in his hands and squeezes it rhythmically to pump blood to the brain and other vital organs.

However, such "open-chest" cardiac massage was attempted rarely and succeeded even more rarely in those old days.

CPR Invention


Cardiopulmonary resuscitation (CPR) is an emergency procedure, performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest.

In late 1950s, James Elam and Peter Safar conducted research on then-existing basic life support procedures including controlling a person’s breathing airway by tilting back his or her head with an open mouth; and using mouth-to-mouth breathing.  Later Safar combined these with a procedure known as closed-chest cardiac massage to become the basic life support method of CPR[6].

In 1958, William Bennett Kouwenhoven, Guy Knickerbocker, and James Jude at Johns Hopkins University has formalized chest compression techniques.  In 1960, they reported their experience with twenty patients in whom they had used closed-chest cardiac massage.  They successfully resuscitated every one of the first twenty patients they treated, fourteen of whom (70%) survived without brain damage or other ill effects. They concluded that

  • "the method... can be used wherever the emergency arises, whether that is in or out of the hospital."

So the Creep Began


In May 1966 the National Research Council of the National Academy of Sciences convened an ad hoc conference on cardiopulmonary resuscitation. The conference was the direct result of requests from the American National Red Cross and other agencies to establish standardized training and performance standards for CPR. Over 30 national organizations were represented at the conference. Recommendations from this conference were reported in JAMA in 1966.[7]

Soon thereafter, all cardiac arrests in U.S. hospitals or outside the hospital (i.e., mobile ICU ambulances) were treated with these methods. In other words, CPR became—and remains today—the "default" treatment for every person who dies.

What's the Problem?[3]


This is how the CPR resuscitation works. First aid practitioners will:
  • Pump on you chest
  • Put a breathing tube down your throat
  • Squeeze oxygen into your lungs
  • Jab you with needles
  • Electrocute your heart
If you ever witness this method, you can understand just how crazy, and creepy, this can be.

Three things may have contributed to CPR creep:
  1. The Hopkins researchers, in their initial study, treated a very narrow spectrum of patients; most were young, healthy people (including several children) whose hearts had stopped during elective surgery, victims of anesthesia mishaps.
    • We now know that many new treatments, studied in a narrow spectrum of patients, aren't nearly as successful when used in a broader patient population. Ignorance of this "spectrum bias" potentiates creep.
  2. Our failure to understand the difference between efficacy and effectiveness[2].
    • Effectiveness relates to how well a treatment works in the practice of medicine (i.e., in the "real world"), as opposed to efficacy, which measures how well treatment works in clinical trials or laboratory studies (i..e, under the ideal conditions of a research study).
    • The fist study of out-of-hospital CPR in 1967 found that 50% of cardiac arrest victims in Belfast were resuscitated successfully. But when doctors in New York tried to replicate these spectacular results on the streets of lower Manhattan, their "mobile ICU" ambulances were able to save only 6% of cardiac arrest victims.
  3. Mass media promote medical creep too.
    • Episodes of television "doctor shows" like ER, perpetuated spectrum bias about CPR and grossly inflated its effectiveness.
    • Researchers found that 2/3 of all (fictiohnal) cardiac arrests portrayed on ER (and other doctor shows) involved young patients who had suffered rare events like drowning or lightining strikes, rather than old people with heart disease.

The Truth—It's Not So Effective in the Elderly


First of all, old people with heart disease account for 90% of cardiac arrests in real-life settings, including Cook County Hospital where stories of ER were based on.[3]

Secondly, large studies involving only elderly patients have documented CPR survival rates as low as zero and as high as 18%, with up to 1/4 of all survivors suffering permanent brain damage[8-11]. Not mentioning that CPR can lead to:
  • Prolonged suffering
  • Severe neurological damage[12]
  • An undignified death

One geriatrician wrote that 36 of his 40 patients (whose average age was 87) told him that they wanted CPR[3]. This confused him until he found that they did not understand the low likelihood of benefit and the potential downside of CPR. After he had discussed the realities with his patients, 39 of the 40 opposed resuscitation.  To conclude, as recommended in [15], patients who are in the dying phase should not be subjected to “cardiopulmonary resuscitation,” as this constitutes a futile and inappropriate medical treatment.

References

  1. Creep (Wikipedia)
  2. Efficacy (Wikipedia)
  3. One Doctor—Close calls, cold cases, and the mysteries of medicine by Brendan Reilly, M.D.
    • Excellent book, which most of this writing is based on. It has debunked many myths in today's medical practices.
  4. Cardiopulmonary resuscitation (Wikipedia)
  5. Flynn, Ramsey (2011-02-18). "A Dying Dog, a Slow Elevator, and 50 Years of CPR". Hopkins Medicine magazine.
  6. History of cardiopulmonary resuscitation (Wikipedia)
  7. Committee on CPR of the Division of Medical Sciences, National Academy of Sciences-National Research Council, Cardiopulmonary resuscitation, JAMA 1966;198:372-379 and 138-145.
  8. Kim,C., Becker,L., Eisenberg, M.S., 2000.Out-of-hospital cardiac arrest in octogen-arians and nonagenarians. Arch.Intern. Med. 160,3439–3443.
    • Octogenarians and nonagenarians have lower survival to hospital discharge than younger patients, but age is a much weaker predictor of survival than other factors such as initial cardiac rhythm. Decisions regarding resuscitation should not be based on age alone. 
  9. Murphy, D.J., Murray,A.M.,Robinson,B.E.,Campion,E.W.,1989.Outcomes of cardiopulmonary resuscitation in the elderly. Ann. Intern. Med.111,199–205.
    • CPR is rarely effective for elderly patients with cardiopulmonary arrests that are either out-of-hospital, unwitnessed, or associated with asystole or electromechanical dissociation.
  10. Ehlenbach et al., Epidemiologic Study of In-Hospital Cardiopulmonary Resuscitation in the Elderly. New England Journal of Medicine. 2009; 361:22.
  11. Five-year survival of patients after out-of-hospital cardiac arrest depending on age.
  12. Chan P.S., Nallamothu B.K., Krumholz H.M., et al. Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest.  N Engl J Med 2013; 368:1019-1026.
    • At hospital discharge, 48.1% of the patients had mild or no neurologic disability, and the rest of the patients had moderate-to-severe disability or were in a coma or vegetative state. 
  13. As Night Draws Nigh (Travel and Health)
    • A writing to commemorate my mother and to describe how I have walked her through the last moments of her life. 
  14. Why Doctors Die Differently (WSJ)
    • During doctors' last moments, they know, that they don't want someone breaking their ribs by performing CPR (which is what happens when CPR is done right).
  15. Ethical decision making in palliative care: cardiopulmonary resuscitation for people who are terminally ill. London: National Council for Hospice and Specialist Palliative Care Services; 2002.
    • Patients who are in the dying phase should not be subjected to “cardiopulmonary resuscitation,” as this constitutes a futile and inappropriate medical treatment.
  16. Cardiopulmonary resuscitation (CPR): First aid (Mayo Clinic)



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