DNR Should Be The Default: PRO debate
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The application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember - 2 weeks in ICU can spare you 5 minutes of difficult conversation.
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DNR Should Be The Default: PRO debate
- 1. BARE KNUCKLE ICU DNR SHOULD BE THE DEFAULT @psirides Wed June 15th
- 2. “First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realising that in such cases medicine is powerless. #Hippocrat 400 BC
- 4. A Brief History of CPR 5 Cases 35yr old under GA 9yr old post GA 80yr old under GA 12yr old under GA 45yr old in ED 1960 And no brain.
- 5. Public Perception of CPR 100 in-patients aged ≥70 years were asked “if you had a cardiac arrest, what would happen?” ‘MisconceptionsAmongElderlyPatients’, Adamsetal2006 81% believed they had ≥50% chance of leaving hospital with no disability 23% believed the chance of no disability was ≥90%
- 6. TV Shows Country No. Episodes Screened No. Cardiac Arrests Witnessed Outcome Casualty, Cardiac Arrest, Medics UK 64 52* 25% survival Grey’s Anatomy, House US 91 46 69.6% ROSC, 71.9% survival to hospital discharge ER, Chicago Hope, Rescue 911 US 97 60 75% ROSC, 67% survival to hospital discharge Star Trek: TNG, DS9 & Voyager Outer Space 526 96 13% ROSC, 9% long-term survival *48% of patients <35 years old
- 7. ON TV, NO-ONE ARRESTS FROM ‘OLD AGE’
- 9. NEJM 1996
- 12. 100% of doctors are trained to perform a procedure BY DEFAULT that 90% of them wouldn’t want themselves
- 13. OHCA=IHCA
- 14. How People Die Murray et al, BMJ 2008
- 15. of IHCA arrhythmias are non-shockable
- 17. Assess Rhythm Non-Shockable CPR For 2 Minutes R E P E A T
- 18. Ebelletal,CriticalCareMedicine2014 38,092 patients who received CPR whilst an in-patient
- 19. 49 DEAD DURING CPR 34 DEAD BEFORE DISCHARGE 7 DEAD BY 1 YEAR 10 ‘ALIVE’
- 20. “I want to die peacefully in my sleep like my father, not screaming & yelling like the passengers on his bus.” Steven Wright
- 22. Dr.Will Cairns
- 25. POOR COMMUNICATION CAUSES HARM FromCrunchGamer1viaYouTube
Editor's Notes
- I realise this is an impossible task. Giving a talk on DNR at a conference almost wholeheartedly dedicated to resuscitation is like talking about right heart failure at an orthopaedic conference. Define resuscitation: is CPR.
- JAMA July 1960 James Jude was the cardiac surgeon who first described closed chest massage. He died this year, aged 87. Ironically, he wasn’t for CPR Evidence drift
- ‘Pneumonic plague’ Trauma predominates. None of these are ‘old age’. British TV series ‘Cardiac Arrest’ (the only show written by a junior doctor) showed people with cancer receiving CPR - with a 100% mortality rate
- For those who say the public don’t believe everything they see on television, I have 2 words for you: PRESIDENT TRUMP
- CPR is the thing that doctor’s don’t want the most
- This is the pinnacle of modern resuscitation Mostly unchanged for 50 years If you do this long enough, some idiot will come along & put you on ECMO
- Interesting definition of ‘high’ - 28-39%. This is SURVIVAL, not ‘neurologically meaningful survival’ CPC 1 is lives independently, 2 is lives in sheltered accommodation, 5 is brain dead
- 100 Elderly patients undergo in-hospital CPR ‘Alive’ or ‘success’ of CPR is usually defined as ‘has a pulse’ This is not a very patient-centric definition There is a similar Japanese study
- Because.. - arrests are either predicted by preceding deterioration so early intervention prevents that person arresting (so CPR is not needed) or... - it is recognised that the patient is dying and that this process is irreversible so management focus is shifted to palliative intent (so CPR is not used as an assault on a dying patient)
- We should not be training 100% of all doctors to perform CPR We should be training 100% of all doctors to talk to patients about not doing CPR
- CPR should be like any other treatment that requires consent ‘Surprise’ question
- CPR is evidence drift at its worst It is an inappropriate treatment for dying Many in-patients have been deteriorating for some time before they arrest If you’ve deteriorated to the point that you need CPR, you are dying Talk to your patients about what CPR means & the likely outcomes Treat it like any other treatment that requires consent Teach your colleagues how to talk to people about not doing CPR I’m not talking about not doing CPR. I’m talking about not doing it as the default