CPR Outcomes in Adults over 80
As the global population ages, the challenges faced by emergency medicine clinicians in managing out-of-hospital cardiac arrests (OHCA) in older adults is becoming increasingly complex. An international multicenter cross-sectional survey from the Journal of the American Geriatric Society, REAPPROPRIATE, sheds light on the prevalence of clinician perception regarding the appropriateness of cardiopulmonary resuscitation (CPR) for individuals aged 80 or older and its correlation with patient outcomes.
The study's findings highlight the grim reality of CPR outcomes for older adults, with a survival to hospital discharge rate of only 2.1%. Despite this poor prognosis, a surprising 18.5% of surveyed clinicians perceived their last CPR attempt as inappropriate. Most CPR attempts involved non-shockable rhythms, further contributing to the overall unfavorable outcomes.
Several factors may contribute to the discrepancy between clinical outcomes and clinician perceptions. The study proposes that clinicians might be influenced by denial, avoiding decision-making due to emotional challenges associated with poor prognosis. Additionally, legal concerns, fear of litigation, and adherence to technical guidelines that emphasize resuscitation without providing space for clinical insight may contribute to the continuation of futile CPR attempts.
The study emphasizes the urgent need for a professional and societal debate on the ethical considerations surrounding CPR for older adults. With a growing number of elderly patients experiencing OHCAs, a paradigm shift in the approach to resuscitation is imperative. Clinicians and patients must be equipped with the knowledge and tools necessary to make ethically informed decisions, considering the unique challenges posed by aging populations.
Suggestions for improvements from the study include:
Interdisciplinary Education: Enhancing clinicians' knowledge about outcomes, prognostic factors, and limitations of CPR is crucial. Education should extend beyond healthcare professionals to include the lay community.
Debriefing and Ethical Reflection: Resuscitation team leaders should encourage open discussions about the appropriateness of CPR attempts within their teams. Debriefing sessions and interdisciplinary ethical reflections can improve decision-making and align practices with ethical principles.
Closed-Loop Systems: Implementing closed-loop systems that provide feedback on patient outcomes to all clinicians involved in a CPR attempt can enhance clinical insight and inform future decisions.
Advance Care Planning: Early discussions and realistic information about CPR should be integrated into advance care planning. Shared decision-making involving patients, families, and clinicians can lead to more informed and ethically sound choices.
By fostering a culture of ethical reflection, interdisciplinary collaboration, and patient-centered care, the medical community can work towards ensuring that CPR is administered judiciously, aligning with the best interests of older patients, and respecting their autonomy and dignity. When it comes to discussing your CPR options at end of life, be sure to ask how the resuscitation may affect you based on your body’s health.