CPR or DNR?

Do Not Resuscitate (DNR) means that if the heart stops, the patient does not want Cardio-Pulmonary Resuscitation (CPR) to try restarting the heart. DNR is only supposed to come into effect when the heart stops, which is rare, but long before that, most doctors give less treatment to people who choose DNR (details in the pamphlet and below). 

Giving someone CPR is described at: University of Washington, American Heart Association, Red Cross, Mayo Clinic. Patients who live to leave the hospital (a sixth to a quarter) usually usually stay alive for years, mostly without injury or mental decline, as discussed in the pamphlet and below. CPR allows organ donation in those who do not live. There are several videos at the bottom of this web page, giving people's experience with CPR. 

Click for a printable 4-page PAMPHLET. At the moment it is better organized and more complete than this web page. Several pages of source notes are in the same pdf as the pamphlet, starting on page 5. You can read, print or ignore them. (Calculations are in a spreadsheet.) Please send comments to dnr@globe1234.com

Here are some of the tradeoffs between DNR and CPR:

 Sources:  

• 2017 data outside hospitals from MyCARES, 2017 Non-Traumatic National Survival Report: page 1 "Bystander witnessed... (16.1)"
• 2007-11 data outside hospitals, on change in mental problems, from Copenhagen data
• 2016 data in hospitals from Heart Disease... 2018 Update: page e357  "IHCA: Adult... Survival to hospital discharge was 25.8%" and page e365 "Survival to hospital discharge... 26.4"
• 2014 data in hospitals, on 64% revival, from "Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest": "acute resuscitation survival (black individuals... 64.1% in 2014; white individuals... 64.0% in 2014"
• 2000-2009 data in hospitals, on change in mental problems, from  Appendix of "A Validated Prediction Tool for Initial Survivors of In-Hospital
  Cardiac Arrest"

Broken Bones: An overlapping  8% to 9% of survivors have broken bones from CPR, and 91-92% do not.
Heart stoppages are rare in hospitals, one per 1,700 patient days (page e356)
We can do better:  Rates will improve as the best practices spread. Survival in hospitals is better on weekdays and in some hospitals. Survival outside is better for some ambulance services.
Mental outcomes can improve in the first 6 months after hospital discharge.
CPR survivors (whose heart stopped in a hospital) had higher frequency of mental problems after CPR than before, based on 12,500 survivors 2000-2009, the most recent study:
Survivors       Survivors
before CPR    after CPR    Difference
        3%                 4%             1%     Comatose
        9%                15%            5%     Severe Mental Problems (dependent on others)
       27%               31%            5%     Moderate Mental Problems (can independently do activities of daily life)
       61%               50%         -11%     No Significant Mental Problems

• Definition of levels of Cerebral-Performance Category (CPC) score
• Hospitals have improved CPR, so these rates are not likely to have deteriorated since this 2000-2009 study.

If no one sees a patient collapse outside a hospital, CPR cannot be done, so there is no difference between DNR and CPR. In a hospital, patients are closely monitored, so heart stoppages are noticed.
Organ Donation: 2015 guidelines say liver and kidneys may be donated if CPR is done, even without success, and all organs can be donated if the patient revives but dies in the hospital. Donations may still be limited by hospital abilities and patient condition.

More Details on CPR

CPR includes pushing the chest in 2 to 2.4 inches, 1.7 to 2 times per second (♪ah ah ah ah stayin' alive♫), while the patient lies on a hard surface (not a bed), in a safe place, until s/he recovers. When a defibrillator (AED) arrives, it gives an electric shock, which converts some unhealthy heart rhythms to a healthy rhythm. After defibrillation the patient may still need more chest compressions, a breathing mask or tube and injections. Quick insertion of a breathing tube used to be standard, but it did not save lives or reduce brain damage. Even after recovery, the heart needs help to recover for a few days, involving many steps such as oxygen, drugs, imaging the blood vessels, and cooling the body. The American Heart Association's goal is that no one should die from heart stoppage.

"Vomiting is the most frequently encountered complication of CPR. If the victim starts to vomit, turn the head to the side and try to sweep out or wipe off the vomit. Continue with CPR... Even CPR performed on strangers has an exceedingly rare risk of infection. There is NO documentation of HIV or AIDS ever being transmitted via CPR."

Most nursing homes lack defibrillators; a few have them, so your choice of nursing home affects how long CPR may take until medics arrive with a defibrillator.  Patients need to be put immediately on a bed board or the floor, since CPR on a bed does not compress the chest enough.

People often write limiting directives, such as DNR requests, on the assumption they'll come into play for old age, coma or dementia. But heart attacks may come any time, putting the directives into effect, so directives need to be treated seriously.

Patients who want full care need to be ready for doctors' resistance. A Houston study said, "All physicians reported interpreting requests to 'do everything' as a 'red flag', a sign to more thoroughly explore what 'everything' meant to the patient or family." Caucasian doctors said such families "might be in denial." Hispanic and African American doctors said such requests could show suspicion of doctors.

Researchers have found that as people decline, they're comfortable with more care, just as people with disabilities are, "Patients often cannot envision being  able to cope with disability... However, once patients experience those health states, they are often more willing to accept even invasive treatments." The researchers also found that for irreversible or terminal illness, "physicians and surrogates frequently have difficulty determining when patients are in these states." These are reasons to choose a representative you trust, who knows your goals. 

Advance Directives for CPR or DNR

Another article discusses medical representatives and directives, and you can put your instructions online for immediate access if medics look.

If you choose DNR, it needs to be signed by a doctor, and a copy of the signed DNR needs to be in your wallet or purse, as well as online, for immediate access. Emergency medics need to see a doctor's signature, in order to honor a DNR. Pittsburgh (UPMC) offers a card to print on pink cardstock and keep with you, with room for a doctor's signature. You can ask medics and the doctor who signs it if it will be acceptable in your state. Medics do not always look for such a card, so you may want a state-approved bracelet or note attached to your driver's license, saying the card is there (links to state rules from American Medical or StickyJ or Caring Advocates).

Some people might prefer CPR, with its chances for good results, combined with an advance directive for suicide if they are among the few who develop a severe disability. Directive and suicide laws do not allow that combination. Even so, you can discuss with your medical representative and doctors whether you want your directive to say, if CPR causes severe mental deterioration, do you want "palliative sedation ... to manage intractable symptoms, maybe through reduction of consciousness or complete unconsciousness"? Directives often call for relief of pain or discomfort "even if it hastens my death". However most patients with mental deterioration turn out to enjoy their lives: the "disability paradox," where people with a severe disability are usually happy in their life, and say they have a good quality of life, so they want to continue, even in the most  severe locked-in state. Their unhappiness, if any, comes from pain, fatigue, lack of control or purpose, and isolation, which can all be minimized.

Directives reduce care long before death: 60% of US surgeons will not offer an operation with more than 1% chance of mortality to patients whose advance directives limit followup care.

A study interviewed patients who had DNR and DNI ("Do Not Intubate" orders. (Questions just covered intubation, though the authors called it "resuscitation.") 58% of patients wanted intubation in some scenarios, which calls into question their care or knowledge in accepting DNI orders.

Patients with a Do Not Resuscitate (DNR) order die sooner, even when they are not very sick, because they are denied many treatments besides CPR, so DNR prevents fine-tuning exactly what you want and don't want. A 2016 editorial from AMA says that:

• "Other studies [7] have shown that DNR patients have higher mortality at all levels of severity of illness, which in theory should not be the case since DNR status should be relevant only in catastrophic situations." The cited study discusses survival after CPR. Even among the healthiest patients, some had a DNR order within 12 hours after CPR, and only 7% of these survived to hospital discharge. Among equally healthy patients without DNR, 70% survived.
• "patients with early orders [DNR on first day of hospital stay] receive less-aggressive treatment overall, including potentially critical interventions, such as blood transfusions, cardiac catheterizations, cardiac bypass surgery, and operations for surgical complications [4, 5]"
• "Qualitative studies might help, as might a more data-driven and patient-centered approach to DNR discussions. However, neither of these approaches is likely in the short term."

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Resuscitation and Myths

Resuscitation works well enough so your chances of leaving the hospital alive are, on average:

• 26% in 2016 if your heart stops in a hospital.  The Heart Association's goal is 38% survival by 2020  85% of these survivors "had good functional status at hospital discharge." (p.e357)
• 16% in the community, if someone sees you fall; goal was 16%
• 9% in a nursing home, 17% for nursing home residents in a hospital
• 12% for people over 90 in a hospital, or on dialysis
• 19% for heart failure patients
• 20% for diabetes or pacemaker patients
• 50-80%  in an operating room

Your chances are already better than this when medics and hospitals use the best practices available (rapid defibrillation, adrenaline, cooling patients, ability to catheterize, etc). The 2020 goal is based on expanding best practices.

Organ donation is not usually possible after a death with a DNR, and it is after CPR. All who have CPR are eligible to donate kidneys and liver, if CPR continues until they reach an operating room. Those who revive and die in the hospital are eligible to donate up to 8 organs if desired. Patients who had CPR donate  1,000 of the 30,000 organs transplanted each year. Donations can be taken from 40% of patients who revive and later become brain dead. An average of 3 organs are taken from each patient who donates organs.

At 26% survival, hospitals need to give CPR to 4 patients to prevent one death. This is far better than other treatments. Even 9% survival in nursing homes means 11 are treated to save one, which  is better than most treatments.

Number Needed to Treat (Number of patients treated, to save one life):

• 11   CPR in nursing home, 9% average survival to hospital discharge
• 8   CPR for patients over 90, or on dialysis, 12% average survival to hospital discharge
• 7   CPR in community, 14% average survival to hospital discharge with good mental capacity
• 6   CPR in community, 16% average survival to hospital discharge, total
• 4   CPR in hospital, 25% average survival to hospital discharge with same mental capacity as admission
• 4   CPR in hospital, 26% average survival to hospital discharge, total

JAMA 2018: Most heart treatments need to treat more patients, for many years, to save a life:

• 24   ARB   CHARM-Alternative trial   angiotensin II receptor blocker
• 21   ARNI   PARADIGM-HF (vs enalapril) trial   angiotensin receptor neprilysin inhibitor
• 18   ACEI   SOLVD trial   angiotensin-converting enzyme inhibitor
• 15   MRA   EMPHASIS-HF trial   mineralocorticoid receptor antagonist
• 14   ICD   SCD-HeFT trial   implantable cardioverter defibrillator
• 14   CRT   RAFT trial   cardiac resynchronization therapy
• 11   ARNI   PARADIGM-HF (vs imputed placebo) trial   angiotensin receptor neprilysin inhibitor
• 8   β-Blocker   MERIT-HF trial  

Bandolier at Oxford (also has Number Needed to Treat for many other treatments):

• 18   ACEI   AIRE trial   angiotensin-converting enzyme inhibitor
• 14   Insulin (intensive schedule)

The NNT Group (also has Number Needed to Treat for many other treatments):

• 83 statins to prevent deaths from all causes in patients with known heart disease

CPR's 9% to 26% odds also look good compared to disasters, where teams search as long as there is even a 1% chance of rescuing survivors. Or if you had cancer, would you choose a treatment with 9% or 26% odds of remission after brief treatment, over an alternative of immediate death? 

Trying CPR is cheap, $181 under Medicare. Further care costs much more, but is only done on the living, or to save organs for transplant.

Doctors' doubts about CPR success contrast with their endorsement of cancer screening, though that rarely saves lives.

Survival rates vary for different types of patients. Survival is average or better for patients with heart attacks, heart failure, stroke, or diabetes. Survival is also higher (25%) when patients are on cardiac monitors, which detect stoppages immediately.

Survival rates are below average, even in a hospital, for:

• heart stoppages at night (16% survival)
• blacks (15%)
• people in poor zip codes (13%)
• over 90 years old (12%)
• on dialysis (12%)
• patients "dependent on others for daily support because of impaired brain function," e.g. dementia (11%)
• people with cancer (10%)
• people with liver failure (10%)
• patients dependent because of brain function who live in nursing homes (9%)

As noted, the goal is to raise these rates, so they will be higher by the time you need CPR.

Ribs are broken in 8% to 9% of patients who are revived by CPR outside of hospitals:

• The rate of rib fractures was the same whether patients got CPR from bystanders or emergency responders
• "Compression-induced injuries detected via routine post-arrest care are likely to be largely insignificant in terms of length of recovery." 
• "chest compressions that enabled survival, whether delivered manually or mechanically, are rarely associated with significant morbidity."
• A training site and emergency responders say that popping sounds are often cartilage loosening, or ribs cracking. One says, "having some broken ribs is a much better outcome than if you stopped cpr due to broken ribs"
• "Injuries of the upper respiratory system were not observed in our patients" [dental, lip, larynx or tracheal injuries]

Defibrillators are in many public places, but a 2004 survey found them in less than a seventh of US nursing homes (except Seattle, which has made a city-wide push for defibrillation).

• 8% in Boston nursing homes

• 11% in Philadelphia
• 13% in Omaha
• 33% in Seattle

Since that study, some states require defibrillators in senior housing, health facilities, sports facilities, schools and large businesses. If you want resuscitation and need to live in assisted housing or a nursing home, it is important to ask about their equipment and policies on using it, and you may need to buy your own.

Defibrillators can help patients whose heart starts fibrillating, and who don't have an implanted defibrillator. Automated external defibrillators (AED) have pads to stick on the patient's skin which measure the patient's heart rhythm. If it is fibrillating, the machine advises a shock which comes through the same pads. The shock stops the heart, so it can restart itself correctly. 

Ventricular fibrillation (VF) decays quickly to a stopped heart, so getting the AED and attaching it within 1-3 minutes is essential. 

However even when the heart is completely stopped (asystole), 13% survive to leave the hospital alive if it stopped in a hospital, 4% in a nursing home, and 2% in the community, because of injections and chest compressions. These figures are striking, though they don't affect decisions for or against resuscitation. The rhythm isn't known until after resuscitation starts, so people need to decide their CPR preferences based on the total survival rate.

The PulsePoint app lets 911 call citizens near a cardiac arrest who've been trained in CPR.

Doctors' Resistance

Three professors from Columbia and Harvard recommend (JAMA 3/7/2012, emphasis added):
"Physicians should not offer CPR to the patient who will die imminently or has no chance of surviving CPR to the point of leaving the hospital."

• They do not define "imminently"
• There is no category of people who have "no chance" of surviving. In fact even people over 90 years old and people on dialysis have over 12% chance of living to leave the hospital. People in poor neighborhoods have 13% chance. Blacks have 15% chance. Heart attack survivors have 26% chance of surviving a later heart stoppage. Where should the cutoff be? How many doctors know the odds for various groups?

Except for some people with "extraordinary" values, they say, 

• "it is, in our opinion, not only ethical, but also imperative, that CPR not be offered...
• "However, the decision not to offer CPR should be disclosed to the patient or surrogate...
• "the intent is to protect the patient from harm and maximize comfort."

They recommend an appeal within the hospital, and not following the last wishes of patients who will die imminently.

TRAINING FOR RESUSCITATION

A Regina Saskatchewan orientation video shows a team coming to revive a "patient" in a hospital. They use an actor and a dummy, showing a wide array of techniques available. The doctor handles timing of an AED, which is handled automatically by the AED outside a hospital. 14 minutes.
youtube.com/watch?v=U1zq4T7MEWw

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U of California San Diego (UCSD) orientation video on how a trauma center helps patients. They do not show resuscitation, since it seems patients would be resuscitated by ambulance crew, though it may be needed again in the trauma center. They show how they evaluate the various wounds. 16 minutes.
youtube.com/watch?v=HcR4enuaEK0

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REAL EXAMPLES OF RESUSCITATION

The Heart Association has training videos. The PulsePoint app lets 911 call citizens near a cardiac arrest who've been trained in CPR.

52-year-old Tony Gilliard from South Carolina narrates a video of his heart stoppage while playing basketball in 2013. CPR and AED brought him back. 2 minutes. youtu.be/v=YrBq_sFV3LA

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62-year-old John Ellsworth's heart stopped in a British street. He needed 3 AED shocks to revive, then was taken to a hospital where they treated him, and eventually placed a defibrillator in his chest. 10 minute video narrated by the BBC series Real Rescues. youtu.be/nxpYuVr53zQ

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71-year-old Nebraska lobbyist Tom Vickers collapsed in 2008 from a heart attack at the state Capitol. CPR and AED administered by a doctor on duty revived him. He was taken to a hospital, where they found 99% blockage in an artery. Video from security camera. no sound. 3 minutes.
News article: journalstar.com/news/local/quick-action-by-many-helps-lobbyist-survive-heart-attack/article_c64eb533-d5bb-5eae-99ee-54a7b12a414e.html
Video: youtube.com/watch?v=fNdDzmcwA0w

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51-year-old Chris Solomons in Britain had a heart attack and felt his hands shake and his limbs tingle. He worked at a site which dispatched helicopter medics, and he was still not feeling well when he got there. The medics there took an EKG, which did not look right so they were getting ready to get him to a hospital, but he collapsed. They used CPR and 2 AED shocks to revive him, and flew him to a hospital where doctors found a blocked artery and opened it with a stent. 13 minutes. He says,

• "I’ve been able to experience so much and if it wasn't for the guys doing CPR on me and the AED they used I wouldn't be here.
• "I cannot say strongly enough how important it is that AEDs are in communities. Not in locked cupboards, but out there, placed where they are needed."

Text: heartrhythmcharity.org.uk/www/media/files/130213-sh-1-Chris_Solomons_case_study.pdf
Video: youtube.com/watch?v=w32PUDL2lb8

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A man collapsed in a car, and police arrived to pull him from the car. They and a passing nurse gave CPR and AED. The wife panicked, swore, prayed, and yelled at her husband not to leave her. An ambulance arrived and took over. The man lived and left the hospital in a few days. The nurse and police were given awards for their fast action. It seems to be filmed from a camera mounted on the first police car. 4 minutes.
youtube.com/watch?v=HxlIAQj4IWY

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An Augusta Georgia video shows two patients in the emergency room at the same time. Many of the comments heard on the video use abbreviated medical language. 11 minutes.

45-year-old runner who collapsed at a race got CPR immediately from other runners, and AED after 12 minutes. He was taken to the hospital and revived with cooling treatment. Revival required a breathing tube, which was removed 2 days later. 

65-year-old woman collapsed at home with husband, went several minutes without CPR. An ambulance crew got some response from her heart, using sodium bicarbonate and another medicine, but she died in the emergency room. youtube.com/watch?v=NWKyXYnvlpM

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CPR saved the life of reporter Steve Lopez, and he wrote how it saved an ex-judge who collapsed while driving alone.

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