March 14, 2013, 6:06 am
New Data to Consider in D.N.R. Decisions
Every year in the United States, about 100,000 hospital patients age 65 and older experience what is known in medical parlance as Code Blue. Their hearts stop, and a medical team is summoned to administer cardiopulmonary resuscitation.
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Depending on the underlying medical problem, some patients will receive an electrical shock to the heart with a defibrillator; others will receive medications meant to restore circulation.
Survival from these catastrophic medical events isn’t the norm; only 18 to 20 percent of older patients in hospitals who suffer cardiac arrest end up leaving the hospital alive. But that is an improvement from years past, when survival rates were even more abysmal .
What has not been clear is what happened to older hospital patients who left the hospital after a cardiac arrest. Now a new study in The New England Journal of Medicine of 6,972 elderly people who survived in-hospital cardiac arrests between 2000 and 2008 gives some answers.
A year after exiting the hospital, 58.5 percent of these older patients were still alive. Of this group, 48 percent had little or no neurological impairment, while 52 percent had moderate or severe neurological damage. Forty percent of older patients who survived CPR returned to life at home; the remaining 60 percent went to nursing homes, rehabilitation facilities or hospices.
The chance of recovering from cardiac arrest declined with age, but even in the oldest of the old — those 85 and older — almost half survived one year after being released from the hospital. Women were more likely to reach the one-year mark than men, for unknown reasons, and black patients were less likely to do so than white patients, perhaps because of poorer follow-up care.
About two-thirds of older patients who survived cardiac arrest ended up readmitted to a hospital within one year — an indication of some level of continuing medical difficulties.
What to make of this data? Certainly, it’s sobering. Cardiac arrest in hospital settings is more often than not a killer, and even when people make it through these medical crises the prospect of brain damage is significant.
But the lead author of the study, Dr. Paul Chan, a cardiologist at the Mid America Heart Institute , part of St. Luke’s Health System in Kansas City, sees reason for hope.
“If you make it out alive, you have a significant chance of being alive one year later,” he said. “We shouldn’t hold a nihilistic attitude toward resuscitating the elderly, given these results.”
Dr. Benjamin Abella, clinical research director of the Center for Resuscitation Science at the University of Pennsylvania Perelman School of Medicine, is also optimistic about the findings. Improvements in resuscitation done in hospitals “have changed outcomes significantly, including among elderly patients,” he said.
Among those improvements are quicker response times to cardiac arrest, advances in performing CPR and, perhaps most important, the growing use of therapeutic hypothermia to reduce brain swelling and inflammation and lessen the potential for cognitive harm. This intervention calls for lowering a patient’s body temperature to a target range of 90 to 93 degrees for 24 hours.
(Survival rates for older adults struck by cardiac arrest outside of hospitals are significantly poorer because expert medical help is not readily at hand and potentially helpful interventions are delayed.)
A cautionary note regarding the new study is in order. Because of the kind of data used, Dr. Chan and his research colleagues were not able to evaluate the health of older patients who survived in-hospital cardiac arrests and quantify how much deterioration occurred after those events. To those who care about the quality of life, not merely its length, this is an important consideration.
Older people and their families may want to use findings from this report in discussions about end-of-life care and preparing advance directives, which can include “do not resuscitate” orders.
“I think physicians should discuss these results with patients and ask what their wishes are should their hearts stop,” Dr. Chan said. Unfortunately, there is no research on how elderly survivors of cardiac arrest rate their quality of life and whether they would choose resuscitation again if they had the opportunity, he noted.
“One of the most important questions to ask is, what is the older person’s current level of functional ability and cognitive status,” Dr. Abella said, observing that “elderly patients with good precardiac arrest function tend to do much better.”
“If an older patient is cognitively intact and in reasonably good health, he or she might want to consider allowing resuscitative care,” Dr. Abella said. “But ultimately, this is a very personal, individualized decision.”
New Data to Consider in D.N.R. Decisions