"I want to keep living and working, so always resuscitate me."
Resuscitation is a tricky, tricky word.
Many healthcare providers use the word "resuscitate" to mean revitalizing a person from a critically ill or very sick state to an alert or vigorous state.
"She collapsed from dehydration, and we resuscitated her with 2 liters of normal saline." (Normal saline is essentially intravenous, or IV, fluids.)
In many cases, resuscitation has a positive connotation. If I had a medical emergency, I would want to be "resuscitated!" I would want to be "revived" back to an alert and vigorous state!
Though the dictionary meaning of resuscitation remains the same when a person goes into cardiac arrest - which means the person's heart has stopped pumping blood and the person no longer has a pulse, and technically the person has died - the essence of resuscitation changes when we talk about resuscitating a person whose heart has stopped functioning.
When a healthcare provider asks a person, "What are your resuscitation wishes?" they are asking about their thoughts on undergoing CPR (cardiopulmonary resuscitation). When healthcare teams talk among themselves about a person's "code status," they are talking about the person's wishes regarding CPR.
"Full Code" means the person would want CPR attempts if their heart were to stop working. "DNR" means "Do Not Attempt Resuscitation," which is the same as "AND" or "Allow Natural Death."
This is where many people become confused about the word "resuscitate" in DNR.
Most people say, "I want to be resuscitated! I want medical care! I don't want the doctors to ignore me and let me lie there if I get sick," when actually "DNR" only refers to resuscitation attempts AFTER a person has gone into cardiac arrest, that is only AFTER their heart has stopped working to pump blood throughout the body.
For the rest of this post, I am only referring to "resuscitation" AFTER the heart has stopped beating and pumping blood.
"I want the shocks, but I don't want the compressions."
"I want the compressions, but I don't want the breathing tube."
Most people, including myself before I entered medical school a couple decades ago, get their information about the resuscitation process from movies and television (TV) (read Post 51: Three Ways to Perpetuate CPR Myths). The problem occurs when a person makes life altering medical decisions based on the big discrepancies between resuscitation on TV and resuscitation in real life.
1. On TV, a person who goes into cardiac arrest receives one or two shocks, and suddenly the EKG (or heart rhythm monitor) shows a regular pattern and all bystanders breathe a sigh of relief.
When a person goes into cardiac arrest and the heart is no longer pumping blood and maintaining circulation, oxygen-carrying blood is not being pumped to the brain.
When first responders, paramedics, and bystanders do chest compressions, they are trying to replicate the "beat" of the heart. They are trying to pump the heart themselves. They push as hard and as fast as possible (at least 100 times per minute) with elbows straightened and locked in an attempt to compress the heart (at least 100 times per minute) located below the rib cage. That is a lot of pressure on the rib cage.
Though some people ask for "gentle CPR," there is no part of CPR that is gentle.
In about half of cardiac arrests, the heart suffers certain types of arrythmias, or malfunctioning of the heart's electrical activity, that causes the heart to quiver and not pump blood. These types of cardiac arrest are called vfib (ventricular fibrillation) or vtach (ventricular tachycardia).
Electric shocks - with the paddles or pads like those shown on TV - are given through the chest to stop this abnormal electrical activity. When electric shocks are given, we are actually stopping the abnormal electrical activity and quivering of the heart, hoping that the heart's natural pacemaker will kick back in and a normal rhythm will restart on its own. This normal rhythm should then cause the heart to pump as it should, generating a pulse.
Giving shocks for a vfib or vtach cardiac arrest is like pressing the Restart button on a computer or telephone that is on, but malfunctioning. You hope that the malfunction will be gone after you press Restart.
If the heart has no electrical activity (like the flatline that is shown on heart monitors on TV), then the heart is not shockable. This type of cardiac arrest is called asystole. In this case, there is no abnormal electrical activity to stop, so shocks are pointless.
Giving shocks for a "flatline" cardiac arrest is like pressing the Restart button on a computer or telephone that is already turned off.
In TV, shocks are commonly given for the flatline. In reality, shocks are never given for this flatline. If in half of cardiac arrests, the heart is in a nonshockable rhythm, like the flatline, what is done in real life?
Chest compressions are performed to buy time until whatever caused the heart to stop can be determined and fixed. Causes include, and are not limited to, lack of oxygen from suffocation, drowning, hemorrhage and significant blood loss; disruption in the heart's normal electrical activity due to severely low or high potassium; and nonfunctioning walls of the heart due to a massive heart attack or massive blood clot in the pulmonary arteries.
In addition to administering chest compressions, while medical responders try to determine and reverse whatever caused the heart to stop pumping, paramedics outside the hospital and healthcare providers in the hospital give medications to constrict blood vessels (which then increase blood pressure and blood flow to the heart that is being manually pumped with chest compressions) and/or medications to attempt to stabilize vfib or vtach abnormal electrical activities.
Unlike in TV, during a resuscitation procedure in real life, no one is pausing to breathe sighs of relief.
2. On TV, a person who regains a pulse after resuscitation for cardiac arrest either a) coughs b) makes a joke.
During the time the heart is not pumping, the person is not breathing. There may be abnormal gasping sounds for the first minute or two, but this is not breathing and the gasping sounds soon stop. First responders, paramedics, or bystanders "breathe" for the person with respiratory equipment or by mouth to mouth.
The person who is resuscitated after cardiac arrest is now a person with a pulse who is still unresponsive. They immediately have one of several types of breathing tubes (also called "advanced airway") placed into or through the mouth. Paramedics manually squeeze "breaths" into the person's lungs by squeezing a self inflating bag attached to the breathing tube. They watch the person's chest rise each time they squeeze in a "breath."
Paramedics know that a person could go into cardiac arrest again at any moment so the goal is to rapidly transport the person to the hospital, where staff and resources are available to manage the potential next cardiac arrest.
In the hospital, the person is connected to a ventilator, whether it be for several hours, several days, or long term.
Unlike in TV, intubation (breathing tube placement) is part of the resuscitation procedure.
3. On TV, a person who is resuscitated in one scene resumes normal day to day living at home by the following scene.
Resuscitation is most successful, which means reviving a person who eventually walks out of the hospital without significant brain damage, when it is performed within 5-10 minutes of cardiac arrest in a younger, "healthy" person. This is the person who has no medical problems and drowns. This is the person who is running a marathon and collapses.
On TV, it is primarily the young, healthy child, teen, or adult who is resuscitated after cardiac arrest from trauma, such as a car accident or gunshot wound, or some other sudden event such as drowning. In real life, it is primarily the frail or elderly person with advanced disease, severe illness, and multiple medical problems whose heart stops and goes into cardiac arrest.
The underlying severe dementia, advanced Parkinson's disease, end stage congestive heart failure/liver failure/kidney failure, end stage chronic obstructive pulmonary disease (COPD), or advanced cancer that caused a person's body to weaken to the point of dying remains an issue even if a frail person's heart is able to be resuscitated.
TV does not show resuscitation in these types of people, though these are the types of people receiving most of the resuscitation attempts in real life.
TV instead shows the person who went into cardiac arrest with a potentially "fixable" issue such as massive blood loss from a gunshot wound.
The chances of surviving (which mean living long enough to leave the hospital, regardless of the extent of brain damage) decrease by 10% for every one minute a person does not receive CPR. Irreversible brain damage starts occurring after about 10 minutes of the brain not receiving oxygen. So there is extreme urgency with multiple people working at multiple places on a person's body after the heart enters cardiac arrest and stops pumping.
TV rarely shows what happens after resuscitation. The best case scenario is that a person leaves the hospital the same person, mentally and physically, as before resuscitation.
In real life, a person may go into cardiac arrest three, four, or eight more times, requiring multiple attempts at resuscitation during that hospitalization before they are unable to be resuscitated from the final cardiac arrest . A person may have too much physical debilitation or cognitive disability to go back to living at home by themselves. Sometimes a family witness what their loved one is experiencing and ask to stop the life prolonging procedures and focus on comfort instead.
Studies show a range of statistics on how many people are able to leave the hospital after experiencing cardiac arrest at home. Out of 100 people, about 85 would not leave the hospital, whether they are pronounced dead at home before even arriving at the hospital, do not survive more resuscitation attempts at the hospital, or ultimately family decide they want to transition to comfort focus rather than life prolongation attempts because of the extent the brain was damaged from lack of oxygen during the cardiac arrest. About 15 of the 100 would be resuscitated at home, hospitalized, and eventually discharged from the hospital, about half of those with brain damage.
These numbers are averages. The older the person, the more frail the person, the more advanced disease the person has, the more medical problems the person has, the longer the time before the person is found and resuscitation started - any of these factors worsen the average.
It would be wonderful if a first responder could simply give one hard thump on your unresponsive frail 80 year old grandma's chest to get her heart beating again. It would be wonderful if she then immediately opened her eyes and said, "I know this great shawarma place..." and raised her hand for a lift up.
Unfortunately, resuscitation in real life just does not work like that.