Resuscitation- what's the point. Cardiopulmonary resuscitation (CPR) is unique as the only medical intervention performed on anyone without explicit contrary documentation. Therefore, CPR need to be understood in terms of societal expectations, legal mandates and professional duties. We also need to understand not just the the likelihood of survival, but also the likelihood of disability and the cost (both literally and figuratively) to patients, healthcare workers, and to an already stretched healthcare system. Even the term 'resuscitation' means different things to different people...and that's before we even wade into such terms as 'autonomy', 'paternalism' and 'patient-focused care'. In short, doctors, nurses patients and families can no longer shy away from discussing CPR: it's time to talk. It can be a remarkable way to prevent premature death, it can also squander finite resources and be the beginning of a terrible ordeal for frail patients and frazzled families.

1. Resuscitation: what’s the point?
Peter Brindley MD FRCPC FRCP Edin
Clinician…& proud to be
Other Stuff:
Professor, Critical Care Medicine, Ethics, Anesthesiology
University of Alberta, Canada

2. Declare your biases
Circa 1780

4. What families think?
The Age ofAcquarius

5. What ICU Doctors think?
The Age of Eos and Tithonus

6. Reality check
Most critical conditions fatal 50yrs ago
Now, >80% (all comers) survive to leave ICU
….But NOT if they arrest
Brindley CJGIM 2010
Brindley & Beed BJA 2014

9. • CPR unless explicit contrary documentation
• >8 billion on ICU (1 billion futile CPR)
• 75% die in hospital; 25% in ICU
• 90% die following w/d or w/h
Finfer NEJM 2013
Brindley BJA 2013
Meaney (and DeCaen ) Circulation 2013
The other reality check

11. Getting the point across
 Indian YogaEdmonton Yoga

12. “JOB-ONE”
Resuscitation
Diagnosis
Disease Management
Procedures
Perioperative-Care
Comfort and recovery
End of Life Care
Paediatrics
Transport
Safety
Professionalism

13. CPR: A Janus Head?
Brindley. Preventing Medical Crashes: Psychology Matters. J Crit Care 2010
Brindley. Cardiopulmonary Resuscitation BJA 2014

14. • Outcome depends most upon:
– Who gets resuscitated
• Arrest type
• If witnessed (or not)
• If reversed within 10 mins
–WHO gets CPR; less HOW
near 100%
Sensitivity
–Van Walraven
Arch Intern
Med 1999
Brindley et al CMAJ ’02
Kutsogiannis et al CMAJ ‘11
Brindley and Beed BJA ‘14

16. In-hospital
cardiac arrest
death
5)Not knowing
when to stop
2)Inadequate communication
1)Lack of
knowledge
3)Inadequate
recognition
4)Inadequate
early response
Inappropriate CPR?
J Reason BMJ
P Brindley Crit Care

17. In-hospital
cardiac arrest
death
4)Not knowing
when to stop
5)Inadequate communication
1)Lack of knowledge
2)Inadequate
recognition
3)Inadequate
early response
CPR: background knowledge
J Reason BMJ
P Brindley Crit Care

18. Survival after adult CPR
(in-hospital wards)
i) <1 in 2
ii) <1 in 3
iii) <1 in 4
iv) <1 in 5
Brindley P.G, Markland, Kutsogiannis CMAJ 2002;
Brindley Critical Care Rounds. 2003/ Brindley Can J Anesth 2005/ Crit Care. 2006

19. Witnessed Arrests
In hospital (non ICU)
Survived Initial Discharged Able to Live
Resuscitation from Hospital Independently
All Arrests 48.3% 22.4% 18.9%
Respiratory 96.3% 55.6% 44.4%
All Cardiac 37.1% 14.7% 12.9%
VT/VF 38.3% 25.6% 21.3%
Asy/PEA 36.2% 7.2% 7.2%
Brindley et al. CMAJ 2002
“<1 in 2” “<1 in 3” “<1 in 4” “<1 in 5”

20. Un-witnessed Arrests (45%)
In hospital (non ICU)
Survived Initial Discharged Able to Live
Resuscitation from Hospital Independently
All Arrests 48.3% 1.0% 1.0%
Respiratory 50.0% 50.0% 50.0%
All Cardiac 20.6% 0% 0%
VT/VF 42.1% 0% 0%
Asys/PEA 15.7% 0% 0%
Brindley et al. CMAJ 2002
“<1 in 2”

21. • Greatest impact on survival:
ARREST TYPE & IF WITNESSED
• Consider all stages:
“ROSC is the beginning of new suffering”.
• ? Universal resuscitation
• “Full code” unless explicitly documented otherwise
• ? Cardiac resuscitation c/t respiratory
• 1-in-2 respiratory arrests survived
Brindley et al. CMAJ 2002;

22. No un-wit cardiac arrest discharged
Safest place to arrest…Vegas casino (>70% Valenzuela NEJM)
Or TV medical drama (>60% Diem NEJM)
No improvement in >60 years
Survival not associated with “chronologic” age
Frailty matters more
Survival worse at night/early am.
More un-witnessed, more PEA/ASY, less staff
Brindley et al. CMAJ 2002; Brindley critical care review 2005

23. & the Expensive Care Unit
? Is survival increased ?
Arrests witnessed
Staff and resources present
? Is survival decreased ?
Patients f-sick
Already receiving ““CPR””
Kutsogiannis DJ et al. CMAJ 2011 (n=510)
Chang SH et al. J Crit Care 2009 (n=202)
Tiam J et al. Am J Resp CCM 2006 (n=49,000)

24.  ROSC incr’d in ICU
59% v 48%
Survival to discharge highest in
CVICU CCU GSICU
75% v 70% v 45%
No effect from arrest time-of-day
Kutsogiannis, Bagshaw, Brindley CMAJ 2011

25. Similar to witnessed in-hospital
Advantage d/t less PEA/ASY
3-month survival not significantly better
No improvement in 2 decades
WHO NOT HOW
Kutsogiannis et al. 2011 (n=510)
ICU post-CPR survival:

26. Inappropriate
CPR
4)Not knowing
when to stop
5)Inadequate communication
1)Lack of background
knowledge
2)Inadequate
recognition
3)Inadequate
early response
CPR survival: recognition and response

27. In-hospital (non-ICU) Cardiac Arrest
63% Pulseless electrical activity/ Asystole
12% Primary respiratory 27% Ventricular fibrillation/
Pulseless ventricular
tachycardia
Brindley et al. CMAJ 2002

28. Least recorded BUT most specific predictor
…of deterioration, “unexpected” ICU
Pulse-ox not a replacement
Education priority
MJA 2009

29. In-hospital
cardiac arrest
death
4)Not knowing
when to stop
5)Inadequate communication
1)Lack of background
knowledge
2)Inadequate
recognition
3)Inadequate
early response
In-hospital arrest…a system failure

30. ECMO & adult cardiac arrest

31. Adult E-CPR?
• 40% survival to discharge (c/t 25%)
• Higher mortality if:
started >30mins; >65 yrs; >2 days ecmo
• Large resource/cost commitment
Shin TG CCM 2011 (n=120); Chen Resusc 2010 (n=122);
Chen Lancet 2008 (n= 59) ; Cardarelli ASAIO 2009 (n=135)

32. Adult ECMO arrest better if:
– Sooner
– Briefer
– Arrest type/ Path (AMI; PE)
WHO
not
HOW
1940's Russian experiment. part 1
Cardarelli et al. ASAIO 2009

33. Inappropriate
CPR
4)Not knowing
when to stop
5)Inadequate communication
1)Lack of background
knowledge
2)Inadequate
recognition
3)Inadequate
early response
CPR survival: recognition and response

34. “everything” v “nothing”
“Assault”
“Natural
Death”
“Neglect”
“Giving up”

35. ICU/ED  RRU
Relationship Repair Unit
• >30% DNAR w/o consent
• 9% “ageism”; 8% “anti-disabled”; 5% “euthanasia”
• 2%: d/t “over resuscitation”
• 6%: pre-emptive decision-making
Beed, De Beer, Brindley. Resuscitation 2014

36. Draft 1

37. Oh, and the OR…
• >10% of OR patients have a DNR
• ‘Widespread confusion…’
– anesthetist’s job involves ‘resuscitation’
– OR death NOT like other death
Ewanchuk M, Brindley P.G. Crit Care 2009
Brindley P.G. BMC Anesthesiology 2012

38. Dr Cheryl Misak, UofT
Am J Respir Crit Care Med 2004; J Med Philos 2005; Chest 2010
Oh…and autonomy

39. WTF : ”””Patient focused care””””?
• What it is :
– Communication
– Partnership
– Includes values
• What it is not :
– Technology-centered
– Doctor-centered
– Hospital-centered
Irwin and Richardson CHEST 2006

40. More ICU v Better Death?
• PFC not collected by QUALY
• EOL care rarely “cost effective”
• Lots of limitations…………BUT
Bryce et al Quality of Death. Med Care 2004
Ward and Teno (commentary) 406-407

41. So what do patients want?
• EOL Survey
• ¾ trade shorter-life for better EOL
– ¼ wouldn’t
• Average 10 months
– Low 7; high 24

42. In summary:
• Resuscitating sick people works
• Resuscitating dead people doesn’t
peter.brindley@albertahealthservices.ca