In-hospital resuscitation of the elderly: Characteristics and outcome

Association of Frailty and Cardiopulmonary Resuscitation Outcomes in Older U.S. Veterans

Objectives: Determine the association between frailty and immediate survival of cardiopulmonary resuscitation (CPR) in older Veterans. Secondary outcomes: compare in-hospital mortality, duration of resuscitation efforts, hospital and intensive care unit (ICU) length of stay, neurologic outcomes, and discharge disposition between frail and non-frail Veterans. Methods: Retrospective cohort study including Veterans 50 years and older, who were "Full Code" and had in-hospital cardiac arrest between 7/1/2017 and 6/30/2020, at the Miami VAMC. Frailty Index for the VA (VA-FI) was used to determine frailty status. Immediate Survival was determined by return of spontaneous circulation (ROSC) and in-hospital mortality was determined by all-cause mortality. We compared outcomes between frail and non-frail Veterans using chi-square test. After adjusting for age, gender, race, and previous hospitalizations, we used multivariate binomial logistic regression with 95% confidence intervals to analyze the relationship between immediate survival and frailty, and in-hospital mortality and frailty. Results: 91% Veterans were non-Hispanic, 49% Caucasian, 96% male, mean age 70.7 ± 8.5 years, 73% frail and 27% non-frail. Seventy-six (65.5%) Veterans had ROSC, without difference by frailty status (P = .891). There was no difference based on frailty status of in-hospital mortality, discharge disposition, or neurologic outcomes. Frail and non-frail Veterans had resuscitation efforts lasting the same amount of time. Conclusions and Implications: CPR outcomes were not different depending on frailty status in our Veteran population. With these results, we cannot use frailty - as measured by the VA-FI - as a prognosticator of CPR outcomes in Veterans.

Intensive care of geriatric patients-a thin line between under- and overtreatment

Demographic developments are leading to an ever-increasing proportion of elderly and aged patients in hospitals at all levels of care, and even more patients from these age groups are to be expected in the future. Based on the projected population development, e.g., in Norway, an increase in intensive care beds of between 26 and 37% is expected by 2025. This poses special challenges for the treatment and management of geriatric intensive care patients. The acute illness is not the only decisive factor, but rather the existing multimorbidity and functional limitations of this vulnerable patient group must likewise be taken into account. Age per se is not the sole determinant of prognosis in critical patients, even though mortality increases with age.

'Why didn't you write a not-for-cardiopulmonary resuscitation order?' Unexpected death or failure of process?

Objective The aim of the present study was to understand the reasons for the delivery of non-beneficial cardiopulmonary resuscitation (CPR) attempts in a tertiary private hospital over 12 months. We determined doctors' expectations of survival after CPR for their patient, whether they had considered a not-for-resuscitation (NFR) order and the barriers to completion of NFR orders. Methods Anonymous questionnaires were sent to the doctors primarily responsible for a given patient's care in the hospital within 2 weeks of the unsuccessful CPR attempt. The data were analysed quantitatively where appropriate and qualitatively for themes for open-text responses Results Most doctors surveyed in the present study understood the poor outcome after CPR in the older person. Most doctors had an expectation that their own patient had a poor prognosis and a poor likely predicted outcome after CPR. This implied that the patient's death was neither unexpected nor likely to be reversible. Some doctors considered NFR orders, but multiple barriers to completion were cited, including the family's wishes, being time poor and diffusion or deferral of responsibility. Conclusions It is likely that futile CPR is provided contrary to policy and legal documents relating to end-of-life care, with the potential for harms relating to both patient and family, and members of resuscitation teams. The failure appears to relate to process rather than recognition of poor patient outcome. What is known about the topic? Mandatory CPR has been established in Australian hospitals on the premise that it will save lives. The outcome from in-hospital cardiac arrest has not improved despite significant training and resources. The outcome for those acutely hospitalised patients aged over 80 years has been repeatedly demonstrated to be poor with significant morbidity in the survivors. There is emerging literature on the extent of the delivery of non-beneficial treatments at the end of life, including futile CPR, the recognition of harms incurred by patients, families and members of the resuscitation teams and on the opportunity cost of the inappropriate use of resources. What does this paper add? This is the first study, to our knowledge, that has demonstrated that doctors understood the outcomes for CPR, particularly in those aged 80 years and older, and that failure to recognise poor outcome and prognosis in their own patients is not a barrier to writing NFR orders. What are the implications for practitioners? Recognition of the poor outcomes from CPR for the elderly patient for whom the doctor has a duty of care should result in a discussion with the patients, allowing an exploration of values and expectations of treatment. This would promote shared decision making, which includes the use of CPR. Facilitation of these discussions should be the focus of health service review.

[Discussing the resuscitation policy at a geriatric ward: the experience of patients or their representatives]

AIM

To identify geriatric patients' and their surrogate decision makers' experience with regard to discussing cardio pulmonary resuscitation (CPR) policy.

METHODS

This is a prospective, observational, explorative survey. During 10 weeks, all patients admitted to a geriatric ward of a general Dutch hospital or their representatives were asked for their experience regarding discussion of the resuscitation policy with the physician in attendance. Discussing this policy is a standard procedure at the first day of admission. We also asked on several factors which could influence their experience and on factors to improve discussing resuscitation policies. The primary outcome was the participant's satisfaction expressed on a scale of 1 to l0 regarding satisfaction with the CPR discussion.

RESULTS

Seventy-six participants were included, of which 29 patients and 47 surrogate decision makers. Discussing the resuscitation policy took an average of 4,5 minutes (SD 3.2) to complete. In 70% (n=53) of cases a do-not-resuscitate decision was made. Discussing the resuscitation policy was experienced positive, with an average rate of 7,8 (SD 1.5). A total of 121 positive comments were made, as opposed to 70 negative comments. When they talked about their resuscitation policy, most patients expressed positive emotional responses. As most important improvements were mentioned: a better introduction to discussing this subject (17%), a better explanation of resuscitation and chances of survival (17%) and providing information prior to admission to the ward, so that patient and surrogate decision maker have been informed that the resuscitation policy will be discussed (12%).

CONCLUSION

Most patients and relatives in this study wished to discuss their resuscitation policy with physicians. Still, there is room for improvement in several respects. Patients and surrogate decision makers are in favour of discussing the standard resuscitation policy with the doctor, and evaluate this conversation with a 7.8 / 10. In order to improve both discussing the CPR policy preparing the patient and his representatives and communicating more extensively during the interview are recommended.

Ethics and medico legal aspects of "not for resuscitation"

Not for resuscitation in India still remains an abstract concept with no clear guidelines or legal frame work. Cardiopulmonary resuscitation is a complex medical intervention which is often used inappropriately in hospitalized patients and usually guided by medical decision making rather than patient-directed choices. Patient autonomy still remains a weak concept and relatives are expected to make this big decision in a short time and at a time of great emotional distress. This article outlines concepts around ethics and medico legal aspects of not for resuscitation, especially in Indian setting.

Partial do-not-resuscitate orders: A hazard to patient safety and clinical outcomes?

BACKGROUND

Patients and families commonly discuss end-of-life decisions with clinicians to create a treatment plan based on patient wishes. In some instances, respect for patient autonomy in making choices may create the potential for patient harm. Medical treatments are often performed in groupings in order to work effectively. When such combinations are separated as a result of patient or surrogate choices, critical elements of life- saving care may be omitted, and the patient may receive nonbeneficial or harmful treatment. A partial do-not-resuscitate order may serve as an example.

LITERATURE REVIEW AND DISCUSSION

The limited literature available regarding partial do-not-resuscitate order(s) suggests the practice is clinically and ethically problematic. Not much is known about the prevalence of these orders, but some clinicians believe they are a growing phenomenon. Medical and bioethics organizations have produced guidelines and recommendations on the use of full do-not-resuscitate order(s) with little mention of partial do-not-resuscitate order(s). Partial do-not-resuscitate order(s) are designed based on the patient's anticipated need for resuscitation and are intended to manage dying in a tolerable manner based on what the decision maker believes is "best." Through an analysis of the medical literature, we propose that a partial do-not-resuscitate order contradicts this "best" management intention because it is impossible for the decision maker, or care providers, to anticipate all possible prearrest and arrest situations. We propose that a partial do-not-resuscitate order highlights larger problems: 1) a misunderstanding of the meaning and scope of a do-not-resuscitate order and 2) a need for discussions around goals of care.

CONCLUSION

Discouraging partial do-not-resuscitate(s) order may help promote more accurate and comprehensive advance care planning.

Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders

BACKGROUND

Recent studies have shown that a new emergency medical services (EMS) protocol for treating patients who suffer out-of-hospital cardiac arrest (OHCA), cardiocerebral resuscitation (CCR), significantly improves survival compared to standard advanced life support (ALS). However, due to their different physiology, it is unclear if all elders, or any subsets of elders who are OHCA victims, would benefit from the CCR protocol.

OBJECTIVES

The objectives of this analysis were to compare survival by age group for patients receiving CCR and ALS, to evaluate their neurologic outcome, and to determine what other factors affect survival in the subset of patients who do receive CCR.

METHODS

An analysis was performed of 3,515 OHCAs occurring between January 2005 and September 2008 in the Save Hearts in Arizona Registry. A total of 1,024 of these patients received CCR. Pediatric patients and arrests due to drowning, respiratory, or traumatic causes were excluded. The registry included data from 62 EMS agencies, some of which instituted CCR. Outcome measures included survival to hospital discharge and cerebral performance category (CPC) scores. Logistic regression evaluated outcomes in patients who received CCR versus standard ALS across age groups, adjusted for known potential confounders, including bystander cardiopulmonary resuscitation (CPR), witnessed arrest, EMS dispatch-to-arrival time, ventricular fibrillation (Vfib), and agonal respirations on EMS arrival. Predictors of survival evaluated included age, sex, location, bystander CPR, witnessed arrest, Vfib/ventricular tachycardia (Vtach), response time, and agonal breathing, based on bivariate results. Backward stepwise selection was used to confirm predictors of survival. These predictors were then analyzed with logistic regression by age category per 10 years of age.

RESULTS

Individuals who received CCR had better outcomes across age groups. The increase in survival for the subgroup with a witnessed Vfib was most prominent on those<40 years of age (3.7% for standard ALS patients vs. 19% for CCR patients, odds ratio [OR]=5.94, 95% confidence interval [CI]=1.82 to 19.26). This mortality benefit declined with age until the >or=80 years age group, which regained the benefit (1.8% vs. 4.6%, OR=2.56, 95% CI=1.10 to 5.97). Neurologic outcomes were also better in the patients who received CCR (OR=6.64, 95% CI=1.31 to 32.8). Within the subgroup that received CCR, the factors most predictive of improved survival included witnessed arrest, initial rhythm of Vfib/Vtach, agonal respirations upon arrival, EMS response time, and age. Neurologic outcome was not adversely affected by age.

CONCLUSIONS

Cardiocerebral resuscitation is associated with better survival from OHCA in most age groups. The majority of patients in all age groups who survived to hospital discharge and who could be reached for follow-up had good neurologic outcome. Among patients receiving CCR for OHCA, witnessed arrest, Vfib/Vtach, agonal respirations, and early response time are significant predictors of survival, and these do not change significantly based on age.

Informed consent and the ethical management of the older patient

Informed consent in elderly patients presents many ethical and legal challenges. Most aging patients are competent to provide consent for medical care. The purpose of informed consent is to promote autonomy, to protect a patient from undesired treatment, and to help the patient to make appropriate medical care decisions that correlate with his or her personal values. A surrogate decision-maker should be sought for an incompetent patient. Advance directives are legally and ethically binding tools by which patients can express their decisions regarding medical care before they lose capacity to do so. Discussion of do-not-resuscitate orders is part of informed consent, and patients' wishes regarding resuscitation in the operating room should be respected. Surrogate consent for participation in research is not necessarily allowed by IRB approval and research protocols.

Cardiopulmonary resuscitation: outcome and its predictors among hospitalized adult patients in Pakistan

Introduction

Our aim was to study the outcomes and predictors of in-hospital cardiopulmonary resuscitation (CPR) among adult patients at a tertiary care centre in Pakistan.

Methods

We conducted a retrospective chart review of all adult patients (age ≥14 years), who underwent CPR following cardiac arrest, in a tertiary care hospital during a 5-year study period (June 1998 to June 2003). We excluded patients aged 14 years or less, those who were declared dead on arrival and patients with a “do not resuscitate” order. The 1- and 6-month follow-ups of discharged patients were also recorded.

Results

We found 383 cases of adult in-hospital cardiac arrest that underwent CPR. Pulseless electrical activity was the most common initial rhythm (50%), followed by asystole (30%) and ventricular tachycardia/fibrillation (19%). Return of spontaneous circulation was achieved in 72% of patients with 42% surviving more than 24 h, and 19% survived to discharge from hospital. On follow-up, 14% and 12% were found to be alive at 1 and 6 months, respectively. Multivariable logistic regression identified three independent predictors of better outcome (survival >24 h): non-intubated status [adjusted odds ratio (aOR):3.1, 95% confidence interval (CI):1.6–6.0], location of cardiac arrest in emergency department (aOR: 18.9, 95% CI:7.0–51.0) and shorter duration of CPR (aOR:3.3, 95% CI:1.9–5.5).

Conclusion

Outcome of CPR following in-hospital cardiac arrest in our setting is better than described in other series. Non-intubated status before arrest, cardiac arrest in the emergency department and shorter duration of CPR were independent predictors of good outcome.