Doctors Are Inconsistent in Estimating Survival after CPR and Are Not Using Such Predictions Consistently in Determining DNACPR Decisions

To withhold resuscitation - The Swedish system's rules and challenges

The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision "Do-Not-Attempt-Cardio-Pulmonary-Resuscitation" (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6-13% of patients dying in Swedish hospitals. According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will. Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions. We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.

Is frailty associated with long-term survival, neurological function and patient-reported outcomes after in-hospital cardiac arrest? - A Swedish cohort study

BACKGROUND

Frailty is associated with poor 30-days survival after in-hospital cardiac arrests (IHCA). The aim was to assess how pre-arrest frailty was associated with long-term survival, neurological function and patient-reported outcomes in elderly survivors after IHCA.

METHODS

Patients aged ≥65 years with IHCA at Karolinska University Hospital between 2013-2021 were studied. Frailty was assessed by the Clinical Frailty Scale (CFS) based on clinical records and categorised into non-frail (1-4) or frail (5-7). Survival was assessed in days. Neurological function was assessed by the Cerebral Performance Category scale (CPC). A telephone interview was performed six months post-IHCA and included the questionnaires EuroQoL-5 Dimensions-5 Levels and Hospital Anxiety and Depression Scale.

RESULTS

Totally, 232 (28%) out of 817 eligible patients survived to 30-days. Out of 232, 65 (28%) were frail. Long-term survival was better for non-frail than frail patients (6months (92% versus 75%, p-value <0.01), 3 years (74% vs 22%, p-value <0.01)). The vast majority of both non-frail and frail patients had unchanged CPC from admittance to discharge from hospital (87% and 85%, respectively). The 121 non-frail patients reported better health compared to 27 frail patients (EQ-VAS median 70 versus 50 points, p-value <0.01) and less symptoms of depression than frail (16% and 52%, respectively, p-value <0.01).

CONCLUSION

Frail patients suffering IHCA survived with largely unchanged neurological function. Although one in five frail patients survived to three years, frailty was associated with a marked decrease in long-term survival as well as increased symptoms of depression and poorer general health.

Medical futility regarding cardiopulmonary resuscitation in in-hospital cardiac arrests of adult patients: A systematic review and Meta-analysis

AIM

For some patients, survival with good neurologic function after cardiopulmonary resuscitation (CPR) is highly unlikely, thus CPR would be considered medically futile. Yet, in clinical practice, there are no well-established criteria, guidelines or measures to determine futility. We aimed to investigate how medical futility for CPR in adult patients is defined, measured, and associated with do-not-resuscitate (DNR) code status as well as to evaluate the predictive value of clinical risk scores through meta-analysis.

METHODS

We searched Embase, PubMed, CINAHL, and PsycINFO from the inception of each database up to January 22, 2021. Data were pooled using a fixed-effects model. Data collection and reporting followed the PRISMA guidelines.

RESULTS

Thirty-one studies were included in the systematic review and 11 in the meta-analysis. Medical futility defined by risk scores was associated with a significantly higher risk of in-hospital mortality (5 studies, 3102 participants with Pre-Arrest Morbidity (PAM) and Prognosis After Resuscitation (PAR) score; overall RR 3.38 [95% CI 1.92-5.97]) and poor neurologic outcome/in-hospital mortality (6 studies, 115,213 participants with Good Outcome Following Attempted Resuscitation (GO-FAR) and Prediction of Outcome for In-Hospital Cardiac Arrest (PIHCA) score; RR 6.93 [95% CI 6.43-7.47]). All showed high specificity (>90%) for identifying patients with poor outcome.

CONCLUSION

There is no international consensus and a lack of specific definitions of CPR futility in adult patients. Clinical risk scores might aid decision-making when CPR is assumed to be futile. Future studies are needed to assess their clinical value and reliability as a measure of futility regarding CPR.