By: Brian Hennon
Conversations about death and dying are incredibly difficult. What makes them even more difficult is the mountain of misunderstanding and misinformation that is floating around.
Several years ago, a physician and I were meeting with a family about a loved one and they were struggling to make some very difficult decisions. One of those decisions was about Cardiopulmonary Resuscitation. As the conversation progressed it became clear this family lacked the information to make an informed decision. It also became clear they had either watched too many medical shows on TV or had been given some very poor advice.
It was in that meeting where I got my first taste of the difficult nature of these discussions, but it was also in this meeting where I started learning how to have these discussions.
Below you will find what I hope is helpful information for engaging in these discussions with patients or members of your own family.
Know the Numbers
70%
The success rate of CPR on television and in movies.1
17%
Actual survival after in-hospital CPR. 2
6.7%
Survival rate for individuals receiving CPR after age 70. 3
2.4%
Survival rate for individuals receiving CPR after age 90. 3
2%
Number of patients with cancer or heart, lung, or liver disease who were resuscitated and survived for six months. 4
20-40%
Patients who survived CPR and could function independently afterwards. 5
2%
People over 85 who suffer cardiac arrest and survive without significant brain damage. 6
2%
Number of adults over 67 with severe chronic disease who are alive six months after CPR. 2
Ask the Right Questions
Most Americans perceive that CPR is what they see on their screens and that perception is reality them. Asking the right questions will increase the chances we can lead people to the right conclusions. Before engaging in any type of serious medical conversation I always like to ask for permission with questions like:
I need to ask you some very difficult questions. Are you okay with that?
This conversation is going to be hard, are you okay if I speak honestly and ask straightforward questions?
Once you have permission to discuss openly, you can proceed with questions like:
Have you ever heard of CPR?
Tell me what you understand about CPR.
Have you ever performed CPR on someone?
Would you be surprised to know that only 17% of people who receive CPR survive?
How do you feel about being kept alive artificially with a ventilator?
Did you know that many patients who survive CPR have to be kept alive with a ventilator?
Would you want to have your heart restarted if it meant lack of independence or brain damage?
State Your Compassion
There’s an old saying that people don’t care how much you know until they know how much you care. These conversations are very difficult to start, but even more difficult to hear, so compassion and empathy are vital. As you are having these conversations, use phrases like:
I can only imagine how difficult this conversation is.
I realize this is a really uncomfortable conversation. Are you okay if we continue?
I can tell that your (mom, dad, grandma, grandpa...) is very special to you and I want to help you make the best decision for them that will lead to as little suffering as possible.
Give the Facts
Being compassionate and empathetic means we have to also be honest. That means we have to share some of the hard truths about CPR. This is a great time to again, ask for permission.
Something like, “earlier I asked you if you are okay with me speaking honestly. Are you still okay with that?” is usually helpful.
How important is quality of life to you?
If we could restart your heart, but your (cancer, heart failure, loved one’s dementia…) would not be cured, would you still want us to do that?
If you knew that restarting your heart means a shattered breastbone, broken ribs, bruised heart, punctured lungs, and possible brain damage, would you still want us to do that?
Close the Conversation
If you’ve gotten this far, now is the time to ask the most important question of them all. This is where you ask for a decision with questions like:
Would you like to discuss any of this farther?
Do you have any questions about everything we discussed?
After all that we’ve talked about, what would you like your code status to be?
For more information, please head to https://www.hopefulhope.org/contact.
References
1 National Library of Medicine (2015). “It isn't like this on TV: Revisiting CPR survival rates depicted on popular TV shows.” https://pubmed.ncbi.nlm.nih.gov/26296584/.
2 New England Journal of Medicine (2012). “Trends in Survival after In-Hospital Cardiac Arrest.” https://www.nejm.org/doi/full/10.1056/NEJMoa1109148.
3 Resuscitation Journal (2015). “Out-of-hospital cardiac arrest in the elderly: A large-scale population-based study.” https://www.resuscitationjournal.com/article/S0300-9572(15)00247-6/abstract.
4 National Library of Medicine (2014). “Long-term outcomes after in-hospital CPR in older adults with chronic illness.” https://pubmed.ncbi.nlm.nih.gov/25086252/.
5 National Library of Medicine (2014). “The chance of survival and the functional outcome after in-hospital cardiopulmonary resuscitation in older people: a systematic review.” https://pubmed.ncbi.nlm.nih.gov/24760957/.
6 National Library of Medicine (2016). “Age-specific prognostication after out-of-hospital cardiac arrest - The ethical dilemma between 'life-sustaining treatment' and 'the right to die' in the elderly.” https://pubmed.ncbi.nlm.nih.gov/27669729/.