- Laura Plitt
- BBC World News
If you are a fan of medical TV series, the scene will be very familiar: a high-pitched sound coming from the hospital ward alerts the doctors on duty that the life of one of their patients is hanging by a thread.
Doctors and nurses rush to assist the patient who has suffered a sudden cardiorespiratory arrest and, after initiating the usual cardiopulmonary resuscitation maneuvers, the patient’s heart beats normally again and his life is happily out of danger.
However, these chest compressions accompanied by shocks electrical devices in the chest and followed by subsequent intubation, aimed at restoring oxygen flow to the lungs, thus preventing damage to the brain and other organs, do not usually generate the promising results that we see in fiction.
“The success of the results show that only between the 20% and 24% those who undergo CPR inside the hospital come out alive, and of those patients only one or two come out without serious neurological injuries “, explains to BBC Mundo Fritz Eduardo Gempeler Rueda, anesthesiologist and coordinator of the Clinical Ethics Service of the University Hospital of San Ignacio, in Bogotá, Colombia.
“Outside the hospital, the possibility of survival is 6% al 7%, and the majority who go into cardiac arrest outside the hospital and survive are left with significant neurological damage, “he adds.
From Madrid, Spain, the cardiologist at the Torrejón University Hospital Juan Ruiz-García tells BBC Mundo that we must not lose sight of the fact that it is an intervention that life jacket.
“It is the only maneuver that we have before a stopped patient, without a pulse, to restore circulation,” he explains in reference to a situation, for example, in which a young person has a sudden stop.
But the problem, he says, is when it is carried out “in the context of a serious disease (oncological, cardiovascular or advanced pulmonary), in a patient with a vital prognosis of months or a few years.”
“If people knew what the prognosis is, surely their desire to want CPR would change, as one study has already shown,” he explains.
“In people who have long-term conditions or who are simply at the end of their life, there is no amount of chest compressions or shocks electrical devices that can help her, “Mark Taubert, professor at the School of Medicine at the University of Cardiff, in the United Kingdom, and an expert in palliative care, tells BBC Mundo.
“It is a very unpleasant moment when CPR is given to a body that is dying peacefully, and it is even worse when that person’s family or friends ask you afterwards: ‘Why did you put him / her through that unworthy moment instead? to let us stay with her / him to say goodbye? ‘”adds Taubert.
If everything indicates that the chances of success are so low and the side effects so severe, why then is it still, in most of the world, a treatment that is administered almost in a generalized way in the face of cardiac arrest?
CPR, as we know it today, was described by the Austrian anesthesiologist Peter Safar in the early 1960s, to treat cardiac arrest during surgery.
“In those cases, where doctors look at vital signs on a monitor continuously, when an arrest is detected, the maneuver is started almost before it starts. There, the cause that led to the arrest is generally known and corrected immediately. Then , the survival can be between 60% and 70%. That is to say, very good “, says Gempeler Rueda.
Such was the success of the procedure used by Safar, that its use was logically expanded out of its initial context.
The reason why it is still applied today in circumstances where it is futile is that few people globally have signed a DNR or advance directive, and this, many experts agree, is due to the distorted vision that the general public, as well as many health professionals, have in relation to this procedure.
This distortion comes in part because the vast majority’s knowledge of CPR comes from series and films that show, in the case of the US, for example, a survival rate of 75%, as revealed by a 2014 study.
Few know besides, the hurt that causes.
“CPR is fast, hard, traumatic. An instructor once said to a colleague: ‘If you don’t you break ribs with your compressions, then you’re not doing it hard enough, ‘”says Taubert.
“Some will survive, but with damage to their brain, lungs, chest, with internal bleeding and pain“, he adds.
The aftermath is not just physical.
“Broken ribs are painful, but anyone would accept that price,” explains Ruiz-García. “The biggest risk is the sequelae neurological“, adds in reference to the injuries that are produced by the valuable minutes that elapse since the brain is without oxygen from the moment in which the arrest occurs until the maneuvers begin.
“You can achieve resuscitation of the heart but then the brain can remain working at half gas or no longer works and the patient remains in a comatose state for life,” he adds.
The degree of deterioration varies, but the vast majority of patients do not return to their previous state.
“Patients can survive but with brain damage. This can range from minor damage with trivial functional effects such as becoming forgetful, to moderate damage with serious functional effects such as a change in personality and the need for help with daily activities, or damage severe with catastrophic functional impairment that eventually leads to death, “he explains in an article by The Conversation Barbara Jean Hayes from the University of Melbourne and Joseph Ibrahim from Monash University in Australia.
For this reason, many doctors believe that CPR ends up increasing the suffering of the patient (and his family), by prolonging the death process.
A difficult subject to broach
The lack of education about it is also due to the fact that it is a sensitive topic that many, both doctors and patients, fear to address.
“End-of-life conversations are not facilitated, time is not invested. It’s hard to talk about death, It is something that was not fashionable until recently and many times it is not spoken for lack of sanitary preparation to establish this conversation “, maintains Ruiz-García.
“At the university, to the doctors they teach us to increase survival, to improve symptomsResearch goes towards that, to prolong life, but there comes a time when it is not possible, “he says.
Furthermore, the medical debate was for a long time focused more on technique than on ethical background.
On the other hand, when in doubt and in the absence of a non-resuscitation order, many health professionals choose to resuscitate, as a safer option.
“If a paramedic comes to a house after receiving an emergency call, most of the time they will assume that CPR is needed. In emergencies, there is no time to make assumptions, or CPR is given (quickly) or not,” explains Taubert. .
Unlike in the US or other countries, “in the UK, doctors can decide not to do the maneuver, but they must be able to justify that decision if their regulatory bodies question it.”
“Many people decide that opting in favor of CPR is the safer approach“, he says.
“So far no one has been sued for administering CPR to someone who might not have wanted it, but many have been punished when they decided not to do it,” he adds.
How to change this situation? The experts consulted by BBC Mundo agree that the key is to educate the population so that they can make an informed decision long before CPR is necessary.
“In one study, hospice patients over 60 were asked if they wanted to receive CPR. About 60% did. After a conference in which they explained its real effectiveness and how it was done, that it was necessary to intubate, and that survival was close to 20%, when they were asked again, the acceptance of CPR decreased to 20% “, explains Gempeler Rueda.
For Taubert, reaching an understanding with the help of the doctor is the basis.
“Talking with health professionals, who can share their point of view on CPR and reach a shared understanding can help,” he says, regarding the premise of signing a do not resuscitate order.
It would also help to clear up doubts about what it really involves: the order refers specifically to cardiac massage and not to other types of interventions to save a patient’s life, such as the injection of intravenous fluids if someone is extremely dehydrated, or transfusion several liters of blood for someone with severe anemia.
“I often tell my patients and their designated relatives that thinking about these problems doesn’t make them happen any faster.”
In the end, “it looks a bit like write a will, It may not be the most pleasant thing to do at first, but once people have made their wishes clear and filled out their own DNR order, or have asked their trusted physician to complete it for them, it is as if a weight had been lifted, “says the palliative care expert.
“As one person once told me: ‘Give me all the treatments you want, but please not that last vicious and unworthy act, which rarely works for people in my situation.”
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Eddie is an Australian news reporter with over 9 years in the industry and has published on Forbes and tech crunch.