To resuscitate or not (bus stop spin off)

[Kiwiology]

True, but somebody with end stage COPD/cancer/renal failure etc who may or may not be housebound but has a very poor quality of life regardless I am not sure the best thing by them is to try and work them

[Bieber]

I agree in principle, but at the same time, it's a lot easier to look at someone who is pulseless and asystolic and take the studies and say "they have almost no chance of survival" than it is to look at someone who is pulseless and in V-fib, had good bystander CPR prior to arrival and a decent chance at being successfully resuscitated with full neurological function and say "well, because they've got multiple co-morbidities and a poor quality of life, we're going to call it"--especially if they aren't a DNR patient. To me, that almost crosses into the realm of euthanasia. On the other hand, I haven't looked at the actual survival rates of patients who code that have multiple co-morbidities and I would venture to guess that even if they're fresh their chances of surviving to discharge are low just because of all those co-morbidities--in which case I would be a little less uneasy about it. I'll have to look at the numbers and think about it some more.

As a quick addendum, I'm not opposed to euthanasia, but I wouldn't be as comfortable with the idea of us deciding that that person's quality of life is bad enough that they shouldn't be resuscitated unless the studies indicate that even a "good" code with someone who has multiple co-morbidities has a low survivability. If it's us deciding to withhold resuscitation not because we can't get them back but because their quality of life sucks, I can't agree with it; if it's us deciding based on the science that even if they have the best chances of surviving the arrest they probably won't because of their co-morbidities, that's a different story.

[Happiness]

Why would that disqualify them? It's quite common.

This is not a concideration when I do CPR for the simple fact of living on an Island in the Pacific that has no surgeries at all.

When I do CPR I am required to follow my guidelines. They do include the what seem to be universal guidelines for not starting CPR for example rigor is set. We all know from experience dead is dead but yet we will in some instances still perform this act. I will do CPR for the sake of the family in some cases and my reasoning is that in my community (and I can only speak to that) they truely want you to do it even if they know what the final result is going to be. The one and only time I have successfully brought someone back, the family even went to the point where the pt was acually medivaced to Vancouver, with the knowledge that the result would most likely be death. I think us as human beings always want to believe in miracles, and in truth miracles do happen so who is to say that the person you might not think as viable is in fact not a miracle waiting to happen.

When it comes to people that are in end stages of a terminal disease, I am a advocate of making sure that the family is aware of DNR orders, both for the hospital and for the home. I also make sure that they know to let the local RCMP know there is an expected death in the family so they have no need to go to the house and disrupt what can be a very cultural event in the community.

This topic is to some degree a very personal senerio in ones career, as we are in this job because we want to do everything in our power to save lives.

Also Kiwi to be able to say that one did everything they could is very important for ones mental health. We are in a depressing job and when you have that little sense of dout, that is what can fester into the start of a persons PTDS. I for one have one call from many years ago of a pt because of CHF.He was so full of lung fluids I couldn't even get to the CPR and I had a hard time with the fact that I never got past A. I delt with the fact that in all my training I assumed I was always going to do my ABC's, I now make sure that my new trainies know that there are those time you will not get past A.

[Kiwiology]

I'm referring to clinical scenarios where resuscitation is not best interests of the patient e.g. those who are dying from cancer or with severe end stage chronic medical conditions (e.g. end stage heart failure or end stage COPD) who are bed/house bound or have a such a severely reduced quality of life they are "waiting to die" and may or may not be on palliative care

What about the guy who sits in his recliner all day attached to an oxygen machine and continuous pump driven hospice meds, needs a carer to feed, toilet and shower him and who has not left the house in three years? Where the fuck is the point in coding him?

Look maybe I'm just too out in left field but I find cardiac arrest resuscitation to be incredibly undignified and brutally invasive and in some scenarios it is far more dignified and humane to not work them; sometimes doing what is in the best interest of the patient is to do nothing especially if they have been down any length of time.

The last cardiac arrest I went to was brutal it was horrendous, six people showed up (including myself) and this poor little old lady stayed just as dead as when she got found on the loo.

[Bieber]

Kiwi, I understand where you're coming from, but to be honest, man, it seems like you're coming at this problem from the perspective of ethics and not from the numbers. And I get it, some of those people with severe illnesses have it very hard and I certainly wouldn't want to be in their shoes. But at the same time, our decision to resuscitate needs to be based on the science and their chances of survival to discharge neurologically intact--not whether or not we think their life is too hard to endure any longer even if it's possible to get them to that point.

There are systems in place for people who do not want to be resuscitated, for everyone else we need to base our decisions on that single question: "How likely is it that we can get a good outcome out of this?" Whether we can or cannot achieve that--irrespective of their general state of health, which I admit will influence the answer to that question--THEN we make the decision to attempt resuscitation based on that factor and that factor alone. Just the numbers. The minute we start making our decisions based on what we individually would want done to us, or based on our own personal beliefs, we stop following the science.

People have the right to a good neurologic outcome if we determine based on our objective assessment that such a thing is possible. People also have the right to refuse any outcome that includes ROSC.

So what do the numbers say, man? Because if the stats say that people with all these significant co-morbidities almost never get a good neurologic outcome then I'll stand right beside you and argue against needlessly pounding on their chests. But I'll only do it for the science, I won't do it because I wouldn't want to be bed bound and unable to care for myself; that's me, that's my choice--and I can only speak for myself.

[Arctickat]

What about the guy who sits in his recliner all day attached to an oxygen machine and continuous pump driven hospice meds, needs a carer to feed, toilet and shower him and who has not left the house in three years? Where the fuck is the point in coding him?

Wow, that's uncanny. You just described my father....I wish he'd hurry up and get it over with to be brutally honest. That is one code i won't waste time working on when it happens.

[paramedicmike]

But at the same time, our decision to resuscitate needs to be based on the science and their chances of survival to discharge neurologically intact...

If this is really the case, why do we work anyone at all?

[Bieber]

If this is really the case, why do we work anyone at all?

Because we are able to successfully resuscitate some people. The changes that have been made in resuscitative care have shown improvements and they'll continue to show improvements as we continue to improve our practice. I'm not saying we should resuscitate everyone that codes, and we certainly shouldn't transport those we don't get back--but for a small subset of people, survival is possible.

[Kiwiology]

I think its important we consider what sort of life they are sent back to even if they get a good neurogenic outcome (which is overwhelmingly not likely)

I'm not talking about nagging bitch of an ex wife or something but you know somebody who is at home with the family on palliative care or who is dying with severely diminished quality of life (+/- palliative care).

I was having this sort of discussion with somebody else, we both agreed if we ever end up getting coded when we're 90 and dying from cancer or housebound or something we haunt whoever decides to call the ambos so good!

Well that won't happen to me cos I got my ass a DNR!

Edited May 14, 2012 by Kiwiology

[paramedicmike]

Because we are able to successfully resuscitate some people. The changes that have been made in resuscitative care have shown improvements and they'll continue to show improvements as we continue to improve our practice. I'm not saying we should resuscitate everyone that codes, and we certainly shouldn't transport those we don't get back--but for a small subset of people, survival is possible.

I hate hypothetical situations. However, let's make this hypothetical for a moment. Successful out of hospital resuscitation rates, with complete neurological function, are less than 10%. Were these numbers applied to a medication, meaning that administration of a particular medication worked less than 10% of the time, that medication would never see the light of day.

So if you are arguing for basing this on a numbers game, why do we try to resuscitate anyone at all?

Just playing devil's advocate. I understand, and to a large extent agree, with the argument Kiwi is making. I find the knee jerk reaction against his argument interesting. What I think those who disagree aren't clearly saying is that we as a society have placed such a high value on human life that we *must* try regardless of the circumstances. It becomes an interesting high wire act to balance one against the other.

edit: woefully misplaced comma.

Edited May 14, 2012 by paramedicmike