Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians

Abstract

OBJECTIVES To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out‐of‐hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN Subanalysis of an international multicenter cross‐sectional survey (REAPPROPRIATE). SETTING Out‐of‐hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the “appropriate” subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the “uncertain” subgroup, and 2 of 107 (1.9%) in the “inappropriate” subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non‐shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non‐shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39–45, 2019

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

“…260 Only recently, more discussion about indications and limitations of CPR has started to take place in the public domain. 106 Such discussions, although from a patient and healthcare provider perspective very relevant, are difficult to appreciate for the lay rescuer. The Ethics writing group continues to support the emphasis on bystander CPR as a key link in the chain of survival.…”

Ethik der Reanimation und Entscheidungen am Lebensende

“…Die enorme Bedeutung von Wiederbelebungsmaßnahmen wird sowohl in der populären Presse als auch in speziellen Medienkampagnen angesprochen, hervorgehoben [ 269 ]. Erst seit Kurzem wurde öffentlich immer öfter über Indikationen und Grenzen der Wiederbelebung diskutiert [ 114 ]. Solche Diskussionen sind für den Ersthelfer schwer zu verstehen, obwohl sie aus Sicht des Patienten und des Gesundheitswesens überaus relevant sind.…”

Can Primary palliative care education change life-sustaining treatment intensity of older adults at the end of life? A retrospective study

“…This suggests an improvement in medical staff awareness of DNR and their abilities to identify inappropriate CPR. A study [10] found the last CPR attempt among patients 80 years or older was perceived as appropriate by 52.4% of the clinicians, 29.1% were uncertain about the appropriateness and 18.5% perceived the CPR attempt as inappropriate. 89.2% CPR attempts involved non-shockable rhythms.…”

“…Although there is no uniform de nition of EOL care intensity [7,8], a systematic review [9] presented three main domains: hospitalization (acute hospital, intensive care unit, emergency department), life-sustaining invasive procedures (resuscitation, intubation, mechanical ventilation, arti cial feeding and dialysis) and potentially life-prolonging treatments (surgery, chemotherapy, radiation, medical imaging, transfusions). There are also studies which explore the appropriateness of CPR in the elderly at the EOL, effective methods of delivering do-not-resuscitate (DNR), and related factors of high intensity treatment [7,10]. In addition to reducing these three domains of treatment intensity, we think that high quality EOL care should also encompass adequate symptom control.…”