Magical thinking

Some incidents from chaplaincy are unforgettable. One was watching a woman get cardiopulmonary resuscitation (CPR) — three times over the course of a day. Twice, she was resuscitated. Death won the last match-up, but not without a fight. Before the attending doctor instructed the code team to stop, the woman’s abdominal area looked like a trampoline. With each compression, her belly heaved and sloshed, probably because her ribs had broken. CPR in the “wild” is not like you see on TV.

People don’t like to think about crisis health care, which is unfortunate. When pandemonium is breaking out, there is no time to thoughtfully consider preferences or research options. Without documentation from a patient, families thrust into sudden decision making mode often request “everything” with misconceptions about what heroic procedures entail and can accomplish. If the situation looks grim, loved ones expect miracles (which by definition doesn’t require a hospital or health care). Wouldn’t a miracle be wonderful! In the modern era, faith in science has usurped religion as the source of miracles.

If 911 is called, paramedics who respond to a person with a heart stoppage will begin CPR. For such patients, first responders and medical personnel are required by law to perform chest compressions, unless the patient has a written and available doctor order that instructs otherwise, such as a Do-Not-Resuscitate (DNR) or Physician Order for Life-Sustaining Treatment (POLST). As the chart shows, the in-hospital success rate for CPR varies, ranging from 15 % for those under age 70 to 0% at ages over 89 (100% failure rate!). One conundrum–the most successful CPR occurs when someone is hospitalized, which indicates there must be some illness or injury already. Risks from CPR include potential for rib fractures, internal organ trauma, and permanent neurological damage.^[3]

How is success defined? Obviously, it would be restoration of a heart rhythm, but what does that mean for the patient: survival for 24 hours, discharged from the hospital to a custodial care facility, or regaining of functionality? Although 72.9 percent of the post-CPR deaths were within 72 hours, sometimes successfully resuscitated patients have permanent neurological impairments.^[4] The Wall Street Journal reported on a 2010 study of more than 95,000 cases of CPR found that only 8% of patients survived for more than one month. Of these, only about 3% could lead a mostly normal life. Despite these statistics, the standard of care requires CPR, without regard for age or underlying disease.

Estimated success rates for CPR^[2]

Notwithstanding technological advances that extend body functioning, death ultimately comes. Unless we admit that death is part of the human condition, we won’t change how we approach end of life. Awareness of reality allows the ability to frame dying in alignment with values. Many people have misconceptions about the effectiveness of procedures. Examples of interventions shown on screens deceive by looking “clean, pretty, and reliable.” Someone who undergoes chest compressions and has underlying disease ends up admitted to an ICU, not sauntering out of the hospital, seemingly little worse for the wear after getting pummeled. Don’t let TV or blogs guide health care decisions, but do ask questions.

As a reality check, patients should keep in mind that doctors don’t want the interventions that they routinely prescribe for the patients: “Almost 90 percent of doctors would forgo resuscitation and aggressive treatment if facing a terminal illness.”^[5] Given that doctors know more about medicine and side-effects, patients should choose cautiously. Especially with elderly patients, those who survive may be worse off physically and mentally than before the ordeal.

There are costs to denial and failure to plan. Decide ahead of time what you would want and write it down. Identify the person who will speak for you if you are unable. Fill out Advance Directives: deliberate, decide, and document AND keep the forms someplace where they can be found.

PS: I am not a doctor and this is not medical advice.

[1] Schneider,

[2] Schneider, 94.

[3] Schneider, 98.

[4] Schneider, 94.

[5] O’Neill, Stephanie, https://www.npr.org/sections/health-shots/2015/07/06/413691959/knowing-how-doctors-die-can-change-end-of-life-discussions

https://www.wsj.com/articles/SB10001424052970203918304577243321242833962