Behind the Code: On CPR in the Hospital

Cardiac resuscitation – a concept which first entered the American health care system in the 1960s – remains controversial. In the pre-hospital setting, it is without doubt a good thing. Studies have shown that early chest compressions and defibrillation save lives. But its role in the hospital setting is far less well-established.

I recently watched the first episode of Boston Med when an ER resident runs a code in the hospital. It is relatively accurate in its depiction. Hospital codes are crowded and chaotic. They tend to degenerate into disorganized care very quickly. The most important thing, when running a hospital code, is to be a large, loud presence in the room – brute force is the only way to establish order in these situations.

Many families wonder whether they should make their family members DNR/DNI. If they were to watch a code, they might be more hesitant to go the “full code” route. It can be violent. The chest compressions often break ribs, and central line access and intubation are invasive procedures to say the least.

That is not to say that codes are pointless – and they do offer the hope of a positive outcome. An article published in The Washington Post, A patient’s death prompts a doctor to assess ‘Do Not Resuscitate’ orders , addresses this. It recounts the story of a gentleman who is DNR but is mistakenly resuscitated. Cardiopulmonary resuscitation saves his life, at least in the acute setting.

I just ran my first code in the hospital – a successful one. There is always a positive feeling in the room when a patient is resuscitated successfully – you watch the monitor as he regains a heartbeat, pulses come back. One life saved today, you think.

But for every one that is saved, many more die – the success rate of CPR is low. In hospital, approximately 44% of patients survive CPR immediately after the event but only 17% of patients survive to discharge. Overall success rates of CPR vary widely, anywhere from 2% to 30%. Interestingly, CPR success rates on television are as high as 75% – which clearly misleads people into believing that CPR can “fix” people.

Cardiac arrest is usually not the primary problem in patients – instead, it is only a sign of an underlying problem. In the case of the gentleman with end-stage cancer, his underlying problem was hyperkalemia, or high potassium. Other patients have underlying problems which are not so easily fixable.

Too many cardiac codes are performed on patients at the end of life. An article published two years ago by MSNBC, Most cancer doctors avoid saying it’s the end, criticizes physicians for not discussing end-of-life issues. Doctors tend to avoid these conversations – and although they may believe that it is for their patients’ sake, it is often more a result of their own discomfort with end-of-life. Patients should not suffer invasive procedures and endless days in the medical ICU during their last days of life, nor should they be made to undergo the valiant life-saving efforts of CPR once they have already passed away peacefully.

As physicians, we need to be more attentive to our patients and we need to address end-of-life issues openly, before patients are too sick to make informed decisions. This end-of-life discussion not only benefits patients by ensuring that their wishes are honored, but it also gives families the peace of mind to make decisions for their loved ones if necessary. This discussion is a difficult but important one. As patients, we should be proactive about discussing these issues with our physicians; we should also be proactive about discussing these issues with our families.

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