Monday, December 14, 2009

Cardiopulmonary Resuscitation

In my book, In Defiance of Death: Exposing the Real Costs of End-Of-Life Care, I discussed the uses and abuses of in-hospital cardiopulmonary resuscitation (CPR). This procedure involves attempting to restart the heart after it has stopped beating. I quoted a paper that found only 10.5% of these patients were alive one year later. I mentioned that if we could decrease the number of resuscitations in half, by excluding those patients with known terminal disease, not only would we save dollars, but more importantly we would allow thousands of patients to have a more dignified and peaceful death.

I quoted Dr. Blackhall who, in The New England Journal (1987), discussed the concepts of patient autonomy and physician responsibility. Basically, he said that if the medical assessment is that CPR has even a remote chance of success it should be offered and the patient with autonomy has the right to refuse the procedure. However, if there is no chance of success, physician responsibility would dictate that CPR should not be done regardless of the wishes of the patient/family. In these situations Dr. Blackhall concluded that both patient and physician must understand that modern medicine cannot indefinitely postpone death.

I also pointed out that since the early 1960's CPR is performed in the hospital as the default position unless there is a specific do not resuscitate order (DNR). This frequently leads to confusion, with CPR being attempted in the majority of cases when it is obvious that it would not be successful. This is the reason that a small percentage of patients receiving CPR leave the hospital alive and fewer still are alive a year later. I suggested a new hospital admission form that would make CPR an ordered event and create an updated advanced directive with physician input to ensure medical feasibility. I also suggested an appeal mechanism in cases of misunderstandings or differences in opinion.

So what is the latest data? Are we using CPR more or less wisely? Dr. W.J. Ehlenbach and colleagues recently published results using Medicare data (reimbursement codes) from 1992-2005 in the July 2, 2009 New England Journal of Medicine. They found 18.3% of CPR patients left the hospital alive. There was no increase in the survival rate over this time course. They found an incidence of 2.73 CPR attempts per 1000 Medicare hospital admissions with survival less for men, the most elderly, those with co-existing disease and those admitted from skilled nursing homes. Strikingly they found that the proportion of patients dying in the hospital having undergone CPR actually increased during this time period. Fewer survivors of CPR were discharged home over the course of the study. People of African descent had higher rates of CPR but with less survival.

Is it just CPR that is now being increasingly used more inappropriately, or is it a reflection of the present style of medicine in this country? In my mind there is no doubt that it is a reflection of our present medical culture. There are presently no mechanisms whereby physicians collectively attempt to use our ever-expanding medical arsenal in an individualized rational manner. We presently have a business model in what is fundamentally a non-business enterprise. These are some of the reasons why we spend much more per person than any other country, have millions uninsured and inferior outcomes. Until these and other basic problems (i.e. lack of primary care, the politically driven Medicare payment system) are addressed, I believe our present attempts at health care reform will be unsuccessful.


Ryan said...

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Doctor Kenneth Fisher said...

Ms. O'Brien,
Thank you for commenting on my blog. I have sent you an e-mail and hope we can collaborate. Best Regards, Kenneth A. Fisher, M.D.

Doctor Kenneth Fisher said...

Ms. Smith,
Thank you for commenting on my blog. I have sent you an e-mail and would very much like to work with you. Sincerely, Kenneth A. Fisher, M.D.