The Ethics of CPR...and Slow Codes!

In light of recent events, I thought it would be appropriate to discuss some CPR-related material, while at the same time dabbling in medical ethics and the "slow code," which many people aren't aware of, even if they do work in a hospital.

I'd venture to guess that most everyone has heard of cardiopulmonary resuscitation, and most people would know that you perform the procedure when someone's heart has stopped beating.  I'm also fairly certain that a ton of people harbor some misconceptions about CPR, including when to start, when to stop, the traumatic nature of the procedure, and the possibility for saving the patient, among other things.  It's actually a pretty complicated (albeit very imperfect) procedure, wrought with inconsistencies between individuals performing it.  Let's talk about the procedure itself first, then we'll get to the ethics, which is a whole other sack of budding potatoes (shout out to TJ!)

Ok, so your 67-year-old uncle, Billybob, just collapsed on the dining room floor after a delicious meal of said potatoes.  He's definitely not responsive, not moving, and not doing much of anything, really.  However, your aunt Bettybob is active enough for the both of them, screaming at the top of her lungs and doing all sorts of unconscious panicky convulsions near his lifeless body.

What next?  After your "Oh **** (insert favorite explitive)" moment, you check Billybob's pulse, and there isn't one.  That instant, not 10 seconds later, not 20 seconds later, you HAVE to start CPR, and you HAVE to give it your full concentration. Tell Bettybob to call 911, and be confident whatever unintelligible utterances she gives to the dispatcher will summon the appropriate help.

Image from CNN

The whole purpose of CPR is to get blood to the patient's brain and, to a much lesser extent, all other vital organs.  That means you have to push hard enough to squeeze the heart ventricles between the sternum and the spine, which requires about 2 inches of sternal depression to accomplish.  This isn't a trivial fact.  Two inches is a big distance, especially for a chest cavity.  The rule is if you think you're pushing hard enough, push harder.  Notice how to hold your hands and where to put them with the above picture.  On top of that, you have to keep a fast rate, of at least 100 beats per minute.  Too slow, and you don't have adequate cardiac output.  Too fast, though, and you don't give the heart enough time to fill before the next beat.  As it turns out, the Bee Gees, despite their girly octaves, made a terrific contribution to medicine with their hit song "Stayin' Alive" (appropriately named, as well!).  Most anyone in the hospital has this song in their head while they're performing compressions, and it gets you a rate around 120-130, which, coupled with excellent, deep compressions, is about as good as you can get for the utility of CPR.  

Memorize that chorus.  It could save your Billybob's life.  

As you can imagine, our Billybob is in for a beating.  Most commonly patients suffer numerous broken ribs, bruises, and the occasional pneumothorax (due to a rib puncturing a lung) during CPR.  In 30 hypothetical minutes, to the Bee Gee's catchy beat (no doubt stuck in your head for the rest of the day, as it should be), a rotating team of 200lb men would pound on his chest 3,600 times.  It isn't pleasant, and I can certainly say I've had the unfortunate experiences of hearing the "snap" of few fragile ribs while performing CPR, especially on the elderly.  Just consider the train wreck equivalent you or someone you care about will be going through when "all resuscitative measures" are taken.  This isn't necessarily a bad thing, just something that isn't often taken into consideration especially when end-of-life decisions are being made in the geriatric population.

Just a few more points, then we'll get to the philosophical/ethical gobbledygook.  So now you're doing CPR on Billybob, pushing really hard on his chest, and you realize you haven't been giving him any breaths.  Its just you and Bettybob, still in her frenzied state, in the house waiting for the EMTs.  Here's another important point, one which has been slightly controversial in the past few years, but one which the American Heart Association has put to rest once and for all in March of 2012.  DON'T GIVE BILLYBOB ANY BREATHS.  I think we're all so put off by the mouth-to-mouth aspect of CPR, that a lot of people might not jump right away to help an unfortunate pulseless soul because they fear swapping spit with this (near) lifeless stranger.  Well fear no longer!  Even if your worst enemy, plagued with a variety of STDs and infected lip rings, manages to lose grasp of his pulse, you can effectively perform superb CPR without inflating his lungs.  Continuous, deep chest compressions are what matter.  The only situations in which you should stop compressions are when you are switching off with someone else, you are delivering a shock through a defibrillator, the patient gets a heartbeat back, or the patient is declared dead.  In our case with Billybob, the only thing we're really trying to do with CPR is to save him time until the medics get there to possibly deliver a shock.

And now the bad news.

Billybob's chances aren't good.  The fact that he lost a pulse puts him in really bad shape, but the fact that you started CPR immediately gives him the best chance he can hope for.  When we talk about successes with CPR, we not only consider if the patient's heart started back up again eventually, but we also account for neurological function.  As an example, if CPR is administered less than 6 minutes after the onset of cardiac arrest, at 10 minutes of CPR time only about 50% of people who survive--we'll get to this in a moment--will have a satisfactory (i.e. awake and communicating) neurologic recovery.  At 30 minutes of CPR in the same patient, that percentage drops to about 2%.  If it takes more than 6 minutes to start CPR, the percentage of survivors with a satisfactory recovery plummets to 20% at 10 minutes of CPR, and is 0% at 15 minutes of CPR.  This is why you generally stop CPR after 30 minutes when resuscitation was started early ( less than 6 minutes), and 15 minutes after CPR was started late ( more than 6 minutes) after the initial arrest.  The reason the percentages are low, even for those with quick initiation of CPR, is because most individuals either do not provide adequate chest compressions or even adequate compressions are not providing necessary blood flow to the selfish brain.  And the final depressing stat about CPR:  The survival rate, at best, meaning the entire procedure is performed wonderfully with perfect chest compressions and the patient has minimal arrest time and relatively quick defibrillation, is about 10%.  This, combined with our previous stats, means that about 5%, at most, will have a satisfactory neurological outcome and survive their ordeal.  It sucks, but not if you or a loved one is the 1 out of 20 with this outcome. If you can administer a shock in the first 3-5 minutes, depending on the study, survival can reach an astonishingly underwhelming 30%, but still amazing compared to later shocks during the process.

The point of all this is that everyone, no matter what their education level or walk of life, could be in the position to save someone's life through proper administration of prompt CPR and good compressions, to the tune of a Bee Gees classic.  If you don't like the Bee Gees, learn the damn song anyway.

I now suggest you grab a beer (I'm sure as hell going to), listen to "Stayin' Alive" again, and put on the good ol' thinkin' caps in preparation for the second half of the longest blog entry I've ever written in my life.

The Ethics of CPR...and other things

At the beginning of the post, I linked to a trending news story in which (in very concise neanderthal-like sentences):  Old lady (87) in old lady living facility goes kerplat.  "Nurse" lady in said facility calls 911.  "Nurse" lady proceeds to tell 911 lady that it is the institution's policy to NOT perform CPR on their residents.  911 lady flips out.  No one else does CPR until the medics arrive like 7 minutes later.  Old lady dies.

This opens a whole kettle of worms, which are in turn infected with parasitic worms, in turn infected with more...well, you get the idea.  Point is, we have a shitload of worms and a nasty kettle that no one is going to eat from ever again.  Let me just preface this by saying that, if I were in "nurse" lady's shoes, and the old lady didn't have some kind of DNR order or advance directive that I was aware of, I would have done CPR on the old lady.  And I think the reason that this story is getting into the news in the first place is because it strikes a dissonant chord with the majority of people's morality eardrums.  It's great news to in fact see that humanity still has perky morality ears, but I think we have to look deeper into why this whole thing bothers us so much...or maybe it doesn't bother you at all, in which case we'd want to look into that too.

For me, this story is bothersome on a few levels.  First and foremost, the "nurse" lady says she is a nurse.  If anyone is going to do CPR for the old lady in this situation, it's her.  Knowing what we know now about CPR stats and outcomes, CPR has to be started immediately if there is to be any hope of recovery.  The old lady, undoubtedly, was starting with a worse projected outcome simply due to her age and whatever other comorbidities she had.  It's even more important, then, to start prompt CPR in this situation if we really want to have a chance of bringing her back from the purported "white light."

What really confuses me in this instance is the conflict between calling 911 and the refusal of care on "nurse" lady's part.  Her intent behind the 911 call was to obtain life-saving care for the old lady (at least I presume that's why you call 911 in this situation), but there was no attempt for bridging care from a medical professional between arrest time and EMT arrival.  If you're trying to save the old lady's life, then you call 911 and do everything you can to save her life.  If you're not attempting to save the old lady's life, as if she had a DNR, then you call the coroner.  You don't, however, half-ass resuscitation efforts when you commit to them, where quick action with CPR is the best (and really only) available treatment option at that point.  I don't claim to know the facility's policies on medical treatment for their residents other than what was said on the 911 transcript.  I have a hunch that their "rule" about not giving residents medical treatment was just stating that they don't dispense medications, provide nursing staff, etc. on the premises, and had nothing to do with whether emergency treatment was offered if needed.  Otherwise everyone in the facility would have to possess a DNR, much like a hospice facility.  So I think this case represents more of a lapse of judgment and moral compass from one or a few individuals involved in the early stages of the old lady's care.

But is CPR always necessarily started after every heart stops?  Of course not.  Let's put aside the cases where advanced directives and DNRs govern that no attempts at resuscitation be performed, and instead look at those cases where the patient has either expressed a desire for life-saving measures or has not made their desires known.  The first case appears easy; we would assume that anyone who wants CPR in the event their heart stops would get it, and for the vast majority this is absolutely true.  We'll save the exceptions (gasp!) for later.  The second case, where the patient has not voiced his or her desires, becomes a little more tricky.  Luckily, the American Heart Association again provides some guidance.  They recommend that resuscitation be performed on all patients unless:

1. The patient has a valid DNAR order.
2. The patient has signs of irreversible death: rigor mortis, decapitation, or dependent lividity.
3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy for such conditions as progressive septic or cardiogenic shock.
4. Withholding attempts to resuscitate in the delivery room is appropriate for newly born infants with —Confirmed gestation <23 weeks or birthweight <400 g —Anencephaly —Confirmed trisomy 13 or 18

So here we have only four instances where CPR can be withheld.  The first describes a DNR (DNAR = Do Not Attempt Resuscitation) situation.  The last describes newborns with devastating conditions.  The second is simply stating that you don't attempt to bring a cold, dead body back to life.   Also, if you are going to do CPR, make sure your patient's head is still attached to their body.  The third instance is where we will spend our time, as there is much room for interpretation.

In that third instance we're basically seeing that the AHA allows for the withholding of CPR based on a description of futility, and in fact their paper defines both qualitative (quality of life) futility and quantitative futility, the latter associated with factors such as arrest time, initial heart rhythm, comorbidities, and an ultimate "calculation" of chance of survival.  AHA recommendation is to take quantitative futility into account when withholding CPR, due to the wide physician-patient disagreement in terms of quality of life assessments.  This is all well-and-good, but we really don't have a way to give a great "calculation" for such an imperfect science, at least not yet.  As they point out in the paper, at what % chance of survival do we withhold resuscitation?  Do we have to wait until there is an absolutely 0% chance of survival?  Is the cutoff 1%, 5%?  In the end, a lot of this quantitative junk gets turned into a qualitative decision anyway, as we really don't have a good idea how to use the calculations we derive.  Basically if the doctor thinks CPR will be futile, that maximum treatment has been administered to no avail, resuscitation does not have to be started.

You're in for a treat now.  Get ready to have your mind fucked and your moral senses irked.  We're going to talk about slow codes.

During a regular Code Blue in a hospital, in which life-saving treatment is likely necessary, organized (and sometimes disorganized) chaos ensues.  Nurses are usually the first on the scene and the first to pull the code alarm.  The operator overhead pages a code blue with the location, and anyone on the code team usually gets a page or a call on their hospital phone to the same effect.  These are the times you see doctors running down the halls, because, as we've discussed, prompt resuscitation is key for improving the odds of survival.  Advanced Care Life Support (ACLS) is initiated, if required, and usually about 10-15 people gather in the patient's room, including nurses, physicians, med students, and sometimes a designated team to provide chest compressions.  This all happens within seconds of the original code being called.

Let's back up for a second and talk about an elderly patient named Mr. Z.  He's a grouchy old man, but he's also very sick.  He's had heart surgery in the past to repair a valve and unblock some coronary arteries, and he had a partial bowel resection for colonic perforation 6 months ago.  Since then, his health has declined, and he had a number of enteric fistulae develop (small openings in the skin tunneling down to the bowel, constantly leaking bowel contents), and he has required increasing amounts of oxygen.  Heart failure is creeping up, and he has not really gotten out of bed since his operation half a year ago.  He's currently the patient with the longest stay in the hospital.  Numerous attempts have been made to inform him of his ill-fated situation, but he insists that all resuscitative efforts be made in the event his heart stops, and his distant, ill-informed daughter agrees.  If his heart actually does stop, it is very likely that Mr. Z would not survive resuscitation due to his comorbidities.

So what if Mr. Z's heart stops beating?  On the one hand, he aggressively stated that he wanted all attempts at resuscitation.  On the other, the man is extremely sick, and the CPR probably wouldn't help much, if at all.  There's no 100% guarantee that it wouldn't work, however, and we may be able to bring the man back to life, albeit at best in the same condition he's in now, probably worse due to all the trauma induced from the procedure itself.  So, pretend for a minute that you're the attending surgeon coming on the general surgery service for the week.  You have to tell your residents what you want done if Mr. Z's heart poops ou in the middle of the night.  What will it be?  Resuscitation or no resuscitation?

Before you answer the question in your own mind, there is one more option.  Hardly discussed outside of the hospital setting, your third option is to perform a slow code on Mr. Z.  At this point in the discussion, all ethicists familiar with this topic start to get sweaty palms and their anal sphincters start puckering.  A slow code is an attempt to clear up a situation like Mr. Z's, to provide him with the requested resuscitation while at the same time allowing nature to take its course, so to speak.  Here's how it works:

When Mr. Z collapses on the floor or wherever, a Code Blue is called just as any other code.  The decision to perform a slow code lies with the physicians, and often times the nurses will be performing their duties as they would during any other code.  However, when the residents and attending physician get their pages about the code, everyone will take their time getting to the room, in hopes that Mr. Z peacefully passes before they start running the code in the room.  Instead of seconds, sometimes it will take the physicians a few minutes to get to the room.  Once there, CPR is continued, but compressions are not as deep, not as frequent, and the goal is to not cause trauma to the chest.  CPR is also not maintained as long as it would be in a full code.  Pretty much no one is brought back from slow codes, as the half-assed effort does not truly circulate any blood to the individual's brain.   It's an elaborate show, good enough to say a code was run but not quite satisfactory to win a tug-of-war game with death.  Of important note, no mention of the words "slow code" or similar jargon appear anywhere on the patient's chart.  It also stirs some pretty strong feelings in a vast array of fields, including ethics, nursing, sociology, anthropology, and law.  It really pulls on some moral heartstrings (ha!), and causes everyone involved to spend some time in reflection about their own values and the field of medicine as a whole.

So now you have three options for Mr. Z:  Full resuscitation, no resuscitation, and a slow code.  Remember, you're in charge of a life here, so choose carefully!

I have to admit that I'm very uncomfortable with the idea of slow codes.  They're deceitful, and they parallel the case of the  "nurse" lady not providing CPR to the old lady at the living facility, where a half-assed resuscitation was attempted as well.  But I'm not convinced that they are entirely evil either, and though I would hope that I am never in the situation of making a decision about running a slow code, I can't say that it would be absent from my repertoire of options.  It's a slippery slope, I wholeheartedly agree.

My last bit of advice for nurses, medical students, and anyone else who finds themselves with a coding patient on their hands without a physician in the room, regardless of a discussion about slow coding the patient was brought up, is to perform a code aligned with the patient's wishes.  If his or her wishes aren't known, I would still give every ounce of my effort into appropriate resuscitation, and wait for a physician to make the final call about the course of the code.  Mr. Z's case resembles that of a patient encountered on my surgical service, and though the patient never coded, the decision was made by the attending to perform a slow code if the situation presented itself.  As an aside, nursing got wind of the plan, and made a formal statement saying that they would not be participating in a slow code if physicians were not present, which, as I mentioned, I find to be perfectly appropriate.

I have much more that I would like to discuss on all of the topics I've covered in this novel of a post, but I'll save everyone's eyes and possibly put up a few smaller posts in the coming weeks.  I'd love to hear other opinions on the "nurse" lady and her actions, as well as the morality of slow codes, as I'm trying to master my moral compass on the matter as we speak.