When someone ‘codes’ on TV, everything is over and done with before the next commercial break. In real life, it’s a horrendous process that generally creates more problems than it was supposed to fix. When I worked in hospitals or doing admissions at a nursing home, I often had to explain what goes on; people just aren’t familiar with what CPR does and doesn’t do. There isn’t a good place to go for information in ‘real life’ terms. People really don’t have the information to make informed decisions. That bothers me as a nurse. The following may be more than some people want to know. But I’m throwing out what I’ve witnessed and learned since becoming an RN in 1985.
CPR was developed by a guy in Norway after witnessing the drowning of a young person (I believe under 20 years old) who was otherwise healthy. That was the original intended demographic for whom CPR was developed- and it’s still the group with the best outcomes. The main cause for infants and children to need CPR is respiratory failure- which is usually easier to fix than when the heart stops for other reasons. For most adults, CPR is needed for cardiac (heart) reasons, and the survival rate – and return to previous level of functioning– is %5 at best. For the others, either it doesn’t help at all, or the person is left in a vegetative state for years, requiring long term care in an institution. Nobody talks about that.
When CPR is done correctly, it can fracture ribs, puncture lungs, lacerate the liver, and still lead to brain damage or death. When someone is pumping on someone’s chest, the pressure has to be enough to move blood in an immobile circulatory system (blood vessels and heart). That pressure can also cause cells to rupture under the pressure, leading to stroke-like brain damage. People get out of being criminally assaulted with less damage. But, it’s the only way to have a second chance for someone whose heart has stopped.
With the newer ‘compression-only’ CPR (no rescue breathing, like before), there isn’t the same amount of oxygen being circulated. That’s a problem in my humble nursey opinion- but it’s the new standard being taught. In a hospital setting, or when EMS arrives in an out-of-hospital setting, they generally ‘intubate’ someone immediately (put a tube into the person’s windpipe) and hook them up to oxygen so it can get to their lungs, which will send oxygenated blood to the body with each ‘pump’ or compression of CPR. Oxygen can only help CPR.
If someone is ‘brought back’ (meaning there’s a heartbeat- nothing else- that is THE criteria for ‘successful’ resuscitation- CPR is no longer needed), they are taken to ICU on a ventilator, and time starts ticking. Now, with the induced hypothermia being done (purposeful cooling of the body to minimize the oxygen demands, thus reducing brain damage, and has its own set of risks), outcomes CAN be better- but that is generally associated with someone who was relatively healthy before their heart stopped. The older someone is, and the sicker they were when their heart stopped, the worse the prognosis. That’s just the truth. CPR is not any sort of guarantee even when it all goes perfectly. It’s a last ditch attempt to save someone’s life. And sometimes there is nothing that will save them, or return them to their previous state of health. But in 2012, it’s all we’ve got.
When someone is warmed up again after they’ve been ‘cooled’, blood vessels dilate- which can add to the brain swelling that happens with oxygen deprivation of any duration. The dilation is the body’s attempt to make more oxygenated blood available to the brain and heart- but it can become part of what ends up being lethal. Yet, it often makes sense to at least try to resuscitate someone. Nobody knows who will have a good outcome- there are just general statistics. And, not to make some sort of attempt for someone who may have ‘a chance’ usually doesn’t make any sense. People want to live- though most also want to be well enough to have some sort of life. Others want to be kept alive no matter what. There really isn’t a right or wrong choice- it’s all very personal, though most people I’ve talked to as a nurse don’t want to be “on machines” or dependent in a nursing home.
When someone has multiple medical issues and/or is older, the chances of CPR bringing them back to their previous quality of life are dismal. When I was diagnosed with leukemia in late March 2010, my blood work and overall condition were such that the nurse I saw the most on the day shift came in and had ‘the talk’ with me. She wanted to find out what I wanted done should things get really dicey. That was tough. I knew the statistics, and I knew that I wasn’t healthy to start with before the leukemia diagnosis. But I was 46 years old…I wasn’t ready to die if there was some way to avoid it. I had (and have) a durable power of attorney for healthcare and a living will. I hadn’t planned on having to talk about it- I always figured that if that stuff was needed, I’d already be out cold. But, I had to make decisions. I opted to be resuscitated if it became necessary- but if things looked grim afterwards, and the quality of life was going to be one of dependence and needing an institution to maintain me, I wanted to have the plug pulled. No camping in a bed for the rest of my ‘life’, not knowing what was going on. I stayed a ‘full code’, but with conditions for afterwards.
I also knew that being taken off of life support doesn’t always mean someone dies. Most of the time, the testing done to determine brain activity will be accurate regarding the ability to breathe once the ventilator is turned off. But some people do have enough reflex activity that they do keep breathing. The reflexes can seem very intentional, but they are just the brain doing its job on autopilot. It can be very difficult for families to see those reflexes and think that the doctors are wrong about their loved one not having any future. Some reflexes seem very purposeful during the time after CPR, even when still on life support. It can all seem very confusing.
During that time I was initially in the hospital for the leukemia, I also had to think about the possibility of needing end of life care, or hospice. If things got to the point where medical science could no longer help me, I wanted comfort care only. Just make sure I didn’t hurt, and let me go home to my dog. In that case, I would have been a ‘no code’. Hospice generally won’t take someone who is still opting to be resuscitated. Their purpose is to help people through the dying process with comfort and dignity, and support their families and friends. They are a wonderful resource for those who no longer have options for recovery.
Anyone can make very specific decisions and have them listed in a living will. It’s also best to have someone (or more than one person) designated as a durable power of attorney for health care. That is NOT the same as a regular durable power of attorney. A ‘POA’ is for financial decisions if you can’t make them. A DPOAH is for health care decisions if you can’t make them for yourself. As long as you are capable of making decisions, the DPOAH is NOT in effect. If you become incapable of making decisions, that is when someone else would legally be allowed to do so. There are other names for the healthcare POA- healthcare proxy, etc. depending on the state (USA). In my opinion, everyone should have both a living will and a power of attorney for healthcare (and the third ‘regular’ power of attorney for financial decisions). Otherwise, the doctors are left with what the family guesses you want. If nobody is around, they have to keep you alive until the point comes where two doctors will legally sign documents stating that you are beyond hope, nobody is coming forward to help with decisions, and you are then taken off of life support.
For any ‘no code’, DNR (Do Not Resuscitate), No CPR, etc, a physician MUST write an order in the chart- otherwise the nurses/healthcare staff MUST begin CPR and resuscitation measures. They are legally bound to do so- even if your family members are standing there telling them to stop. There has to be a legal order in the chart. Having your wishes known is so incredibly important, so that they are carried out.
Talk to your own family about what you want done. Tell your doctor, and get the living will and power of attorney for healthcare/healthcare proxy signed, witnessed, and put into your medical record (your doc’s office and your preferred hospital). Give copies to all people named as your decision makers. Don’t leave things up to someone else to decide. It’s a horrible process for them to watch you deteriorating, and if they know what you want, it helps them not feel like they’re giving up on you.