Discussion
Following on from another thread, let's discuss DNACPRs.
http://en.wikipedia.org/wiki/Do_not_resuscitate
In short, these stop ambulance and hospital crews from having to undertake futile resuscitation attempts on those patients where it would not work.
Elderly and/or those with chronic illnesses are very very unlikely to survive a cardiac arrest but, unless a DNACPR is in existence, then ambulance and hospital staff HAVE TO attempt resuscitation, by law (yes, I know there are exceptions but generally, and in the vase majority of cases it has to be attempted).
We all die, and DNACPRs allow us to die with dignity when our time comes.
CPR can do one of two things: it can save a life or it can prolong death. As I said in another thread:
I do not understand why family resist setting up a DNRCPR for a loved one. Maybe if they saw, as I have done, the trauma of a resuscitation on a frail/elderly/ill person when it is not going to work anyway they would think differently.
I would be interested in other people's thoughts on this.
http://en.wikipedia.org/wiki/Do_not_resuscitate
In short, these stop ambulance and hospital crews from having to undertake futile resuscitation attempts on those patients where it would not work.
Elderly and/or those with chronic illnesses are very very unlikely to survive a cardiac arrest but, unless a DNACPR is in existence, then ambulance and hospital staff HAVE TO attempt resuscitation, by law (yes, I know there are exceptions but generally, and in the vase majority of cases it has to be attempted).
We all die, and DNACPRs allow us to die with dignity when our time comes.
CPR can do one of two things: it can save a life or it can prolong death. As I said in another thread:
I said:
I am a Paramedic and I have (and will be again) been in the unfortunate position of being called to elderly people with chronic medical conditions who have died, often peacefully. However, law dictates that if it happened in front of people and I get there within 20 minutes then I have to undertake full resuscitation. (Massive generational: lots of things to consider).
This means, instead of letting someone die peacefully, they are pulled onto the floor, have their ribs broken though CPR, have needles stuck in their arms (or needles drilled into their legs), have tubes put down their throat and drugs pumped into them. Then they might be subject to rapid transport to hospital where they might be put on a "thumper" (compressed air machine which continues CPR and yes it is as brutal as it sounds).
Then they will die, after suffering all that trauma, in hospital instead of in bed.
There is such a misunderstanding about DNACPRs. Many/most seem to think it means "no treatment" and to "plan to let the person die". It means nothing of the sort. It simply means that all treatments will be available to the patient, except resuscitation, which will not work anyway.This means, instead of letting someone die peacefully, they are pulled onto the floor, have their ribs broken though CPR, have needles stuck in their arms (or needles drilled into their legs), have tubes put down their throat and drugs pumped into them. Then they might be subject to rapid transport to hospital where they might be put on a "thumper" (compressed air machine which continues CPR and yes it is as brutal as it sounds).
Then they will die, after suffering all that trauma, in hospital instead of in bed.
I do not understand why family resist setting up a DNRCPR for a loved one. Maybe if they saw, as I have done, the trauma of a resuscitation on a frail/elderly/ill person when it is not going to work anyway they would think differently.
I would be interested in other people's thoughts on this.
my grandfather died in his sleep one morning, as my grandmother was there, noticed him stop breathing and called 999, someone arrived and had to perform CPR on him.
it's not nice for her to have to see that, he died peacefully in his sleep.
if I ever get to 80 I'll be signing my own. A that said in 60 years we will all have fake hearts and be flying around in spaceships
it's not nice for her to have to see that, he died peacefully in his sleep.
if I ever get to 80 I'll be signing my own. A that said in 60 years we will all have fake hearts and be flying around in spaceships
I think that they are an invaluable tool, that are often misunderstood. If applied correctly, they do offer genuine dignity in death.
Currently, I work on NICU and I have seen some good applications of DNR forms in cases where children have been left severely brain damaged following delivery at birth and would go forward with severe disability.
I think that they are often perceived as a 'we want your relative to die as quickly as possible' form. End of life care is definitely something we need to have more public discussions on in the UK.
Currently, I work on NICU and I have seen some good applications of DNR forms in cases where children have been left severely brain damaged following delivery at birth and would go forward with severe disability.
I think that they are often perceived as a 'we want your relative to die as quickly as possible' form. End of life care is definitely something we need to have more public discussions on in the UK.
I like the USA system with POLST forms (I think currently only in some states, not all) which can work through ALL the interventions, specific scenarios, what to do (and not do) in particular circumstances.
There are chronic conditions and chronic conditions though - I think it's important to be quite careful about language and differentiating between "sooner or later this person IS going to die of leukaemia, when their heart stops restarting it would literally only be in order for it to stop again hours later" and "this person with advanced MS/MND/severe cerebral palsy etc etc is living a happy and interested life between periods of acute illness and if they can survive this episode will go back to enjoying that life, regardless of their severe condition and their shorter life expectancy".
There are chronic conditions and chronic conditions though - I think it's important to be quite careful about language and differentiating between "sooner or later this person IS going to die of leukaemia, when their heart stops restarting it would literally only be in order for it to stop again hours later" and "this person with advanced MS/MND/severe cerebral palsy etc etc is living a happy and interested life between periods of acute illness and if they can survive this episode will go back to enjoying that life, regardless of their severe condition and their shorter life expectancy".
OP, some observations ...
- You need to explain the process in terms of who does what and how. The Wiki article indicates that "the DNR request is usually made by the patient or health care power of attorney" but you need to provide more in terms of what needs to be put in place and how and by who.
- In the case of the request being made by the patient; I'm guessing that in all but a few cases, the patient isn't going to think of this themselves. People who have elderly relatives usually spend the time, where it's possible, to talk about trivial nice stuff like football or the weather or how the rest of the family are getting on. Getting a DNR sorted out is a topic of conversation I'm not going to be having.
- In the case of the PoA sorting it out, you need to explore some of the softer issues and maybe say what sort of medical criteria might apply.
- Would it not be better to focus on the law changing such that paramedics are empowered to make a case by case judgement?
- Do you have experience from your own family you could share?
- While I don't disagree with your point, my first and lasting thought is that; "it's easy for you to say".
Edited by Kiltie on Tuesday 25th February 12:31
To help clarify what it entails (i.e not the misconception that it is the withdrawal of treatment) I explain as follows:
Should you die do you want us to try and resurrect you?
If it is clear that attempting CPR is futile I will not start CPR.
The above applies when someone has had appropriate treatment and despite this is dying. Out-of-hospital cardiac arrests can be a different kettle of fish when the cause is not immediately obvious (although it still stands that you are trying to bring someone back from what, untreated, within seconds becomes death.)
Should you die do you want us to try and resurrect you?
If it is clear that attempting CPR is futile I will not start CPR.
The above applies when someone has had appropriate treatment and despite this is dying. Out-of-hospital cardiac arrests can be a different kettle of fish when the cause is not immediately obvious (although it still stands that you are trying to bring someone back from what, untreated, within seconds becomes death.)
Thanks for starting this thread JB - I think a lot of people should be made a lot clearer about what DNACPR involves. I don't really have much idea myself, like many who get all soft-eyed when seeing tv adverts of the likes of the BHF and Vinnie Jones doing his life saving CPR, which in truth in the short film looks like it wouldn't bring a mouse back to life it's so gently applied. Does that give a false picture? - ie he ain't breaking that person's ribs in a million years!
I hear that a lot of GPs carry around a request 'not' for CPR should they collapse in the street because of the ribs being broken etc. Is this really true? Is it a rumour or tale, or do your ribs get broken if CPR is applied correctly? I note you mention it. I have not ever seen it mentioned elsewhere, or am I just naive?
My dad died of cardiac arrest because the medics couldn't get there in time. Could a bystander have really saved his life? There were plenty of them but not one knew what to do. But they would have had very little time anyway.
I hear that a lot of GPs carry around a request 'not' for CPR should they collapse in the street because of the ribs being broken etc. Is this really true? Is it a rumour or tale, or do your ribs get broken if CPR is applied correctly? I note you mention it. I have not ever seen it mentioned elsewhere, or am I just naive?
My dad died of cardiac arrest because the medics couldn't get there in time. Could a bystander have really saved his life? There were plenty of them but not one knew what to do. But they would have had very little time anyway.
To reply to a couple of points:
Defibrillation gives a fairly potent electrical shock in an attempt to correct a heart rhythm that itself is not compatible with life (ventricular fibrillation or pulseless ventricular tachycardia). Most machines are automatic i.e apply the pads and let the machine decide what to do.
Defibrillation gives a fairly potent electrical shock in an attempt to correct a heart rhythm that itself is not compatible with life (ventricular fibrillation or pulseless ventricular tachycardia). Most machines are automatic i.e apply the pads and let the machine decide what to do.
It is only a rumour that GPs don't want CPR. The people most likely to benefit are those that are younger, in previously reasonably good health and where something sudden (and reversible) has happened. When resuscitating we consider these reversible causes known as the '4 Hs and 4 Ts. If I was found without a pulse then I would want CPR. Chances decrease out of hospital, and decrease very rapidly with length of time from collapse to CPR and the application of a defib. It is something like a 6% chance of survival with out of hospital CPR. The chance of return to good quality of life is a lot lower than that.
I'm sorry, I'm confused. I thought the following ...
Have I got this wrong?
- CPR is chest compressions with (or without) ventilation / artificial respiration ("the kiss of life").
- CPR is to keep the blood flowing to supply oxygen supply to the brain until something is available to actually start the heart working by itself.
- Typically a defibrillator is used / required to start the heart.
- It's not possible to start the heart of someone in cardiac arrest using CPR alone.
Have I got this wrong?
CPR is cardiopulmonary resuscitation - so yes, help with both circulation and breathing.
CPR can keep someone alive long enough for their heart to sort itself out and return to a survivable level of function without other intervention, in some cases. These cases are bloody lucky but far from unheard of. Some types of arrhythmia would be included in this if I understand correctly.
Sometimes CPR itself reverses the cause of the cardiac arrest - for example when the heart has stopped beating effectively due to oxygen deprivation, getting oxygenated blood circulating again (by doing CPR) might actively improve things, not just stop the person from dying. It might be that the person continues to need help with their breathing but then stays out of cardiac arrest.
With a bit of luck one of the medics will be along at some point to improve on my unhappily-educated layperson's understanding of it.
CPR can keep someone alive long enough for their heart to sort itself out and return to a survivable level of function without other intervention, in some cases. These cases are bloody lucky but far from unheard of. Some types of arrhythmia would be included in this if I understand correctly.
Sometimes CPR itself reverses the cause of the cardiac arrest - for example when the heart has stopped beating effectively due to oxygen deprivation, getting oxygenated blood circulating again (by doing CPR) might actively improve things, not just stop the person from dying. It might be that the person continues to need help with their breathing but then stays out of cardiac arrest.
With a bit of luck one of the medics will be along at some point to improve on my unhappily-educated layperson's understanding of it.
BlackVanDyke said:
CPR is cardiopulmonary resuscitation - so yes, help with both circulation and breathing.
CPR can keep someone alive long enough for their heart to sort itself out and return to a survivable level of function without other intervention, in some cases. These cases are bloody lucky but far from unheard of. Some types of arrhythmia would be included in this if I understand correctly.
Sometimes CPR itself reverses the cause of the cardiac arrest - for example when the heart has stopped beating effectively due to oxygen deprivation, getting oxygenated blood circulating again (by doing CPR) might actively improve things, not just stop the person from dying. It might be that the person continues to need help with their breathing but then stays out of cardiac arrest.
With a bit of luck one of the medics will be along at some point to improve on my unhappily-educated layperson's understanding of it.
Wiki article (CPR can keep someone alive long enough for their heart to sort itself out and return to a survivable level of function without other intervention, in some cases. These cases are bloody lucky but far from unheard of. Some types of arrhythmia would be included in this if I understand correctly.
Sometimes CPR itself reverses the cause of the cardiac arrest - for example when the heart has stopped beating effectively due to oxygen deprivation, getting oxygenated blood circulating again (by doing CPR) might actively improve things, not just stop the person from dying. It might be that the person continues to need help with their breathing but then stays out of cardiac arrest.
With a bit of luck one of the medics will be along at some point to improve on my unhappily-educated layperson's understanding of it.
) is more consistent with my understanding.Wiki said:
Cardiopulmonary resuscitation (CPR) is an emergency procedure for manually preserving brain function until further measures to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest.
Wiki said:
CPR alone is unlikely to restart the heart. Its main purpose is to restore partial flow of oxygenated blood to the brain and heart. The objective is to delay tissue death and to extend the brief window of opportunity for a successful resuscitation without permanent brain damage. Administration of an electric shock to the subject's heart, termed defibrillation, is usually needed in order to restore a viable or "perfusing" heart rhythm.
Sorry if I'm being fik.Very quick reply, as I'm heading off to work...
Cardiac arrest is when the heart either stops beating or beats in such a way that it does not pump blood effectively.
If it stops, then CPR is what is required to pump the blood until it restarts. You need to address the reason why it has stopped in the first place (Google reversible causes for cardiac arrest) but particularly in the elderly, you are very unlikely to do this, and CPR is futile.
If the heart does not pump effectively, it might be "quivering", like a muscle spasm. This is the sort of thing which happens to younger people (like footballers who collapse) and in this case you need CPR and you need to use a defibrillator. A defib uses a shock to STOP the heart (a reset, if you like) and then you try to restart it with CPR.
And yes, breaking ribs is a truly horrible experience.
Elderly is more a state of the body than age. I have met people in the 50's who are "old" and then those in their 70's who are not. You have to look at the whole picture to include their health and medical history.
Sorry, need to go to work....!
Cardiac arrest is when the heart either stops beating or beats in such a way that it does not pump blood effectively.
If it stops, then CPR is what is required to pump the blood until it restarts. You need to address the reason why it has stopped in the first place (Google reversible causes for cardiac arrest) but particularly in the elderly, you are very unlikely to do this, and CPR is futile.
If the heart does not pump effectively, it might be "quivering", like a muscle spasm. This is the sort of thing which happens to younger people (like footballers who collapse) and in this case you need CPR and you need to use a defibrillator. A defib uses a shock to STOP the heart (a reset, if you like) and then you try to restart it with CPR.
And yes, breaking ribs is a truly horrible experience.
Elderly is more a state of the body than age. I have met people in the 50's who are "old" and then those in their 70's who are not. You have to look at the whole picture to include their health and medical history.
Sorry, need to go to work....!
Correct.
It has been over 3 years since I last attended an adult arrest, 7 months since my last paediatric (unsuccessful) and only 4 days since my last neonatal (patient already discharged home).
CPR only provides the compressions, and current APLS/ALS guidelines (http://www.resus.org.uk/) suggest 4H's and 4T's of reversible causes of cardiac arrest:
H's
1) Hypoxia (low oxygen - COPD etc)
2) Hypovolaemia (blood loss, GI losses, etc)
3) Hypo- / hyperkalaemia / metabolic (kidney trouble etc)
4) Hypothermia
T's
1) Thrombosis - coronary or pulmonary (includes atheromatous plaques causing coronary embolism)
2) Tamponade - cardiac (blood around the heart inside the pericardium that stops the heart pumping due to pressure)
3) Toxins (poisonings/drug OD)
4) Tension pneumothorax (air outside the lungs compressing the lung)
All of the above should be able to be assessed and reversed by the attending health care provider (paramedic, GP, hospital doc), in order to provide adequate resus.
There are some other important things to be aware of. In children, the most common cause of arrest is a respiratory cause. Regardless of the pathology, most cases of arrest in children, are due to a cessation of breathing and arrest through hypoxia, which is why the APLS (advanced paediatric life support) guideline is slightly different to in adults (ALS). The same reversible causes remain. We more often see asystole or PEA in children as well (see below) but fortunately arrests in children in hospital are less than in adults. Another caveat to this, is neonatal life support (NLS). The reversible causes are different, due to different physiology, and the protocol is very different again. There is no defibrillation in the NLS protocol, however it can still be used for rhythm disturbance in neonates. In NLS, at delivery of the newborn child, respiratory support is often required (inflation breaths) and this isn't out of the ordinary (budding parents take note). If you get to the CPR part of the algorithm, the only reason is to push oxygenated blood from the lungs to the coronary arteries (2cm or so) in order to restart the heart. When considering CPR or drugs (vanishingly rare) then you are in a very bad situation indeed (edit - the SH*T hitteth the fan)
Defibrillation, is the 'resus' you see in Casualty/Holby City etc. This is where Hollywood and ITV demonstrate how with some casually applied electric paddles and shouting 'CLEAR!!' you can bring anyone back to life. In reality, in your local A&E or medical ward, defibrillation is only used for two (commonly - there are again some small print applications for rhythm disturbance and I'm not discussing D.C cardioversion here!) rhythm disturbances. 1) Ventricular fibrillation (VF) and 2) pulseless ventricular tachycardia (VT). We can only shock a person who demonstrates these rhythms, otherwise you're firing electricity through a heart that won't respond, and in the case of PEA (pulseless electrical activity), you can send the person into asystole (que shouts of "WE GOT A FLAT LINER.... etc). The paddles don't often bring someone back to life as they do in the films...
Further to above, the age at which someone is 'old' is very much determined by co-morbidities. A 55yr old with terminal prostate cancer, bone/brain and lung metastesis, might want a DNR in place, whereas a 82yr old, with no other co-morbidities, might do well to make sure they don't have one, as they can reasonably expect a few months/years if there was an obvious cause for the arrest - sepsis or pneumonia etc.
Therefore, the decision to initiate CPR (by this I mean resusitation), should be made on a patient by patient basis. The difficulties come when this hasn't been discussed with patient (and more likely with the family). In cases of elderly/chronic illness patients with multiple co-morbidities, resus often prevents the inevitable, or not at all, it is a grim way to go. In 5 years of practice, working in A&E and on acute wards, I could count the successful arrests I've been to on one hand.
I've been to arrests where people have lost all continence as their muscles relax after death, so had to kneel in sh*t as i've performed chest compressions. I wouldn't want it for my 99yr old granny should she be admitted any time soon, and I will be sure to discuss it with her medical team when she is (hopefully she will die peacefully at home in her sleep). I would, however, want everything done should my wife (28yrs) have a cardia arrest in a car accident or similar. Not because I'm married to her, but the chance of success due to a reversible cause, and the chance that she has a successful recovery is better and to go on an have some quality of life. If she were brain dead and on a ventilator, then no - NB: we have discussed this, she is a GP.
My final thoughts (sorry for going on a bit) are this:
1) If you have an elderly relative with co-morbidities, YOU should ask the medical team what THEIR resusitation plan is
2) The plans should be discussed openly with family members and patient, a good clinician should be capable of this
3) REMEMBER THE PLANS CAN BE CHANGED - and should be reviewed often
It has been over 3 years since I last attended an adult arrest, 7 months since my last paediatric (unsuccessful) and only 4 days since my last neonatal (patient already discharged home).
CPR only provides the compressions, and current APLS/ALS guidelines (http://www.resus.org.uk/) suggest 4H's and 4T's of reversible causes of cardiac arrest:
H's
1) Hypoxia (low oxygen - COPD etc)
2) Hypovolaemia (blood loss, GI losses, etc)
3) Hypo- / hyperkalaemia / metabolic (kidney trouble etc)
4) Hypothermia
T's
1) Thrombosis - coronary or pulmonary (includes atheromatous plaques causing coronary embolism)
2) Tamponade - cardiac (blood around the heart inside the pericardium that stops the heart pumping due to pressure)
3) Toxins (poisonings/drug OD)
4) Tension pneumothorax (air outside the lungs compressing the lung)
All of the above should be able to be assessed and reversed by the attending health care provider (paramedic, GP, hospital doc), in order to provide adequate resus.
There are some other important things to be aware of. In children, the most common cause of arrest is a respiratory cause. Regardless of the pathology, most cases of arrest in children, are due to a cessation of breathing and arrest through hypoxia, which is why the APLS (advanced paediatric life support) guideline is slightly different to in adults (ALS). The same reversible causes remain. We more often see asystole or PEA in children as well (see below) but fortunately arrests in children in hospital are less than in adults. Another caveat to this, is neonatal life support (NLS). The reversible causes are different, due to different physiology, and the protocol is very different again. There is no defibrillation in the NLS protocol, however it can still be used for rhythm disturbance in neonates. In NLS, at delivery of the newborn child, respiratory support is often required (inflation breaths) and this isn't out of the ordinary (budding parents take note). If you get to the CPR part of the algorithm, the only reason is to push oxygenated blood from the lungs to the coronary arteries (2cm or so) in order to restart the heart. When considering CPR or drugs (vanishingly rare) then you are in a very bad situation indeed (edit - the SH*T hitteth the fan)
Defibrillation, is the 'resus' you see in Casualty/Holby City etc. This is where Hollywood and ITV demonstrate how with some casually applied electric paddles and shouting 'CLEAR!!' you can bring anyone back to life. In reality, in your local A&E or medical ward, defibrillation is only used for two (commonly - there are again some small print applications for rhythm disturbance and I'm not discussing D.C cardioversion here!) rhythm disturbances. 1) Ventricular fibrillation (VF) and 2) pulseless ventricular tachycardia (VT). We can only shock a person who demonstrates these rhythms, otherwise you're firing electricity through a heart that won't respond, and in the case of PEA (pulseless electrical activity), you can send the person into asystole (que shouts of "WE GOT A FLAT LINER.... etc). The paddles don't often bring someone back to life as they do in the films...
Further to above, the age at which someone is 'old' is very much determined by co-morbidities. A 55yr old with terminal prostate cancer, bone/brain and lung metastesis, might want a DNR in place, whereas a 82yr old, with no other co-morbidities, might do well to make sure they don't have one, as they can reasonably expect a few months/years if there was an obvious cause for the arrest - sepsis or pneumonia etc.
Therefore, the decision to initiate CPR (by this I mean resusitation), should be made on a patient by patient basis. The difficulties come when this hasn't been discussed with patient (and more likely with the family). In cases of elderly/chronic illness patients with multiple co-morbidities, resus often prevents the inevitable, or not at all, it is a grim way to go. In 5 years of practice, working in A&E and on acute wards, I could count the successful arrests I've been to on one hand.
I've been to arrests where people have lost all continence as their muscles relax after death, so had to kneel in sh*t as i've performed chest compressions. I wouldn't want it for my 99yr old granny should she be admitted any time soon, and I will be sure to discuss it with her medical team when she is (hopefully she will die peacefully at home in her sleep). I would, however, want everything done should my wife (28yrs) have a cardia arrest in a car accident or similar. Not because I'm married to her, but the chance of success due to a reversible cause, and the chance that she has a successful recovery is better and to go on an have some quality of life. If she were brain dead and on a ventilator, then no - NB: we have discussed this, she is a GP.
My final thoughts (sorry for going on a bit) are this:
1) If you have an elderly relative with co-morbidities, YOU should ask the medical team what THEIR resusitation plan is
2) The plans should be discussed openly with family members and patient, a good clinician should be capable of this
3) REMEMBER THE PLANS CAN BE CHANGED - and should be reviewed often
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