CPR Not Always the Answer

Q:  Last year I survived a nearly fatal heart attack, and although I am lucky to be in good health today, I am concerned that if I have another heart attack, I may survive only to be a "vegetable."

I don't want to be a burden to my wife and family, and I don't want to live if I have no quality of life. On the other hand, I know firsthand how CPR can save a life. How do I make sure doctors caring for me understand my wishes? Do I need to make a decision about whether or not to undergo CPR now, in advance?

A:  Cardiopulmonary resuscitation is an amazing medical technique. CPR was developed to revive victims of near-drowning and heart attacks to restart a stopped heart and mouth-to-mouth breathing to fill empty lungs.

Patients who receive CPR have already died; that is, they have no heartbeat and don't breathe on their own. After CPR, most survivors remember nothing about the experience except a sore chest upon awakening.

Ethical problems began when CPR was used in patients who were hospitalized and were chronically or terminally ill. Research shows that very few patients who have metastatic cancer, renal failure or serious infections can be brought back to life once their hearts stop.

For instance, in an average 100 sick hospitalized patients, only 33 people will survive the initial resuscitation effort and only eight will be alive six months later. About two will be left in a "persistent vegetative state." However, these statistics do not apply to you now, since you are in good health living at home. CPR is much more likely to help you.

When patients are critically or chronically ill, they sometimes wish to forgo resuscitation. On the other hand, they may want to receive CPR. Since physicians recognize that some patients may choose to have their families and friends surround them at the time of death rather than the CPR team, they sometimes recommend forgoing CPR because the chance for a meaningful survival is low and the burden of CPR may be high. (After CPR, patients are usually cared for in an intensive care unit, with its high technology, high cost and more limited visiting hours.)

A hospitalization or a clinic visit may be the occasion for an ongoing, thoughtful, sensitive discussion about resuscitation with your doctor. These discussions should occur in a quiet environment; the language should be simple; questions should be encouraged; understanding should be checked; and physicians should strive to improve their communication skills in this regard.

Even with this in mind, the decision to receive or to forgo CPR or other medical care may remain full of difficulties, ambiguities and emotion. But if you've communicated your thoughts to your physician and to your agent in your power of attorney for health care, they can help ensure that you receive medical care in the way they know you want.

For more information on this topic, see "No Code" Does Not Mean No Care and Advance Planning is Crucial in Health Care Emergencies.

Julie L. Mitchell, MD, MS, is an Assistant Professor of Medicine at the Medical College of Wisconsin. She practices internal medicine at the Froedtert & Medical College General Internal Medicine Clinic - East. Her column also appears in the Milwaukee Journal-Sentinel.