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« Nurse refuses to do CPR, » read one ABC’s caption TV news in California. « The 911 switchboard’s pleas were ignored. » Several days earlier, an elderly woman in a senior living facility had gone into cardiac arrest. The dispatcher has assigned an employee to perform CPR or CPR. But the employee refused.
« Is there anyone who is willing to help this lady and not let her die? » the operator said. He made local news, which sparked a national outcry and prompted a police investigation. But the woman was already dead: her heart had stopped. And according to her family, the woman wanted to « die naturally and without any kind of intervention that would prolong her life ».
So why the controversy? It boils down to a widespread misconception about what CPR can and can’t do. CPR can sometimes save lives, but it also has a dark side.
The discovery that chest compression could circulate blood during cardiac arrest was first reported in 1878, from experiments on cats. It wasn’t until 1959 that researchers at Johns Hopkins applied the method to humans. Their excitement at its simplicity was clear: « Anyone, anywhere, can now initiate cardiac resuscitation procedures, » they wrote. « All you need are two hands. »
In the 1970s CPR courses were developed for the public and CPR became the default treatment for cardiac arrest. Flight attendants, coaches and babysitters now often need to be certified. The appeal of CPR is that « death, instead of a final and irrevocable step, becomes a process that humans can manipulate, » writes Stefan Timmermans, a sociologist who has studied CPR.
« This is the realest of emergencies and you give people the simplest procedures, » Timmermans told me. « It sounds too good to be true, » he said, and it is.
Most people learn what they know about CPR from television. In 2015, the researchers found that survival after TV CPR was 70%. In real life, people are the same way believe that survival after CPR is greater than 75%. These seem like good odds, and this may explain the attitude that everyone should know about CPR and that everyone who experiences cardiac arrest should get it. Two bioethicists observed in 2017 that « CPR has acquired a reputation and aura of almost mythical proportions », such that to hold onto it might seem « equivalent to refusing to extend a rope to someone who is drowning ».
But the real odds are grim. In 2010 a review of 79 studies, which involved nearly 150,000 patients, found that the overall survival rate from out-of-hospital cardiac arrest had barely changed in thirty years. It was 7.6%.
Bystander-initiated CPR can increase those odds to 10%. Survival after CPR for in-hospital cardiac arrest is a little better, but still only about 17%. The numbers get even worse with age. A study in Sweden found that survival after out-of-hospital CPR dropped from 6.7% for patients aged 70 to just 2.4% for those aged over 90. Chronic diseases are also important. One study found that fewer than 2 percent of patients with cancer or heart, lung, or liver disease were revived with CPR and survived for six months.
But that’s life or death – even if the odds are grim, what’s the harm in trying if anyone will survive? The damage, it seems, can be considerable. Chest compressions are often physically, literally harmful. « Fractured or cracked ribs are the most common complication, » he wrote the original Hopkins researchers, but the procedure can also cause pulmonary hemorrhage, lacerations of the liver and ruptures of the sternum. If your heart is resuscitated, you have to contend with potential injuries.
A rare but particularly dire effect of CPR is called CPR-induced consciousness: chest compressions circulate enough blood to the brain to wake the patient during cardiac arrest, who may then feel ribs popping, needles entering skin, a breathing tube that passes through the larynx.
The traumatic nature of CPR may be why well half of patients who survive wish they hadn’t received it, even if they lived.
It’s not just a matter of life and death if you survive, but quality of life. Injuries sustained from resuscitation can sometimes mean a patient will never come back to their senses. Two studies found that only 20-40% of elderly patients who survive CPR are able to function independently; others have found slightly better recovery rates.
An even bigger problem than quality of life is brain injury. When heart activity stops, the brain begins to die within minutes, while the rest of the body takes longer. Doctors are often able to restart a heart only to find that the brain is dead. From 30% of survivors of cardiac arrest in the hospital will have significant neurological disability.
Again, older patients fare worse. Only 2% of survivors over 85s escape significant brain damage, according to one study.
CPR can be harmful not only to patients, but also to healthcare professionals. In 2021, A study found that 60% of providers experienced moral distress from futile resuscitation and that these experiences were associated with burnout. Another study it linked intrusive memories and emotional exhaustion to difficult resuscitations. Holland Kaplan, a physician and bioethicist, told me that « bad experiences distant they outnumber the good ones, unfortunately. »
She has written about performing chest compressions on a frail elderly patient and feeling his ribs snap like twigs. He found himself wishing « to hold his hand in his last moments of death, instead of crushing his breastbone. » He told me he had nightmares about it. She described noticing his eyes, which were open, while he was performing CPR. Blood spurted out of her endotracheal tube with each squeeze.
« I felt like I was hurting him, » she told me. « I felt he deserved a more dignified death. » It’s no wonder many doctors dislike CPR, e.g choose don’t get it yourself.
The real purpose of CPR is to « connect the person to an intervention, » Jason Tanguay, an emergency physician, told me. « If they can’t get it, or there isn’t one, then what is it accomplishing? » This is the crucial insight that doctors have and most others don’t. CPR is a bridge, nothing more. Sometimes it spans the distance between life and death if the cause can be quickly reversed and if the patient is young enough and relatively healthy. But for many, that distance is too great. « The act of resuscitation itself cannot be expected to cure the inciting disease, » wrote the Hopkins researchers in 1961.
A terminal cancer patient who is resuscitated will still have terminal cancer. In those cases, the more humane approach may be to ease the pain of the dying process, rather than build a bridge to nowhere.
How can doctors help patients make these choices ahead of time? Part of it is education. Studies have found that half of patients changed their wishes when they did learned the true survival rates of CPR, or after seeing a video depicting the reality of CPR.
Another part is communication. According to one survey, 92% of Americans believe it is important to discuss end of life care, yet only 32% did. Doctors (or patients) should start these conversations early, especially for those who are elderly or have chronic medical problems, so that their wishes are known in advance if they experience cardiac arrest.
Language also matters. Doctors often ask if patients « want everything done » if their heart stops. But this puts a burden on patients and families. « Who wants to feel like he doesn’t want everything done for their loved one? » Kaplan says. Instead, if CPR was likely futile, doctors might recommend « allowing natural death » instead of « do not resuscitate, » suggests Ellen Goodman, director of a nonprofit that encourages end-of-life conversations.
« Give people something they can say yes to, » she told me. Physicians have the knowledge and experience to guide patients in choosing measures that may benefit them, rejecting those that may harm them, and aligning interventions with their wishes and values. The most important thing, instead of always acting, is to ask.
Clayton Dalton is a writer in New Mexico where he works as an emergency physician.