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“Nurse refuses to perform CPR,” read the caption on an ABC news broadcast in California. “911 dispatcher’s requests ignored.” Several days earlier, an elderly woman at a seniors’ home had suffered a cardiac arrest. The clerk instructed an employee to perform CPR, or cardiopulmonary resuscitation. But the employee refused.
“Is there anyone out there willing to help this lady and not let her die?” said the clerk. It made the local news, sparking a national outcry and prompting a police investigation. But the woman was already dead – her heart had stopped. And according to the family, the woman had wanted to “die naturally and without any form of life-prolonging intervention”.
So why the controversy? It comes down to a widespread misunderstanding of what CPR can and cannot do. CPR can sometimes save lives, but it also has a dark side.
The discovery that chest compression could circulate blood during cardiac arrest was first reported in 1878, from experiments on cats. It was not until 1959 that researchers at Johns Hopkins applied the method to humans. Their excitement over its simplicity was evident: “Anyone, anywhere, can now initiate CPR procedures,” they wrote. “All it takes are two hands.”
In the 1970s, CPR classes were developed for the public, and CPR became the standard treatment for cardiac arrest. Flight attendants, trainers and babysitters are now often required to be certified. The allure of CPR is that “death, instead of a final and irreversible passage, becomes a process that can be manipulated by people,” writes Stefan Timmermans, a sociologist who has studied CPR.
“This is the truest of emergencies, and you give people the simplest procedures,” Timmermans told me. “It seems too good to be true,” he said, and it is.
Many people learn what they know about CPR from TV. In 2015, researchers found that survival after TV CPR was 70%. In real life, people similarly believe that survival after CPR is over 75%. That sounds like good odds, and this may explain the attitude that everyone should know CPR, and that everyone who experiences a cardiac arrest should receive it. Two bioethicists observed in 2017 that “CPR has acquired a reputation and aura of almost mythic proportions,” so that withholding it can seem “akin to refusing to extend a rope to someone who is drowning.”
But the true odds are grim. In 2010, a review of 79 studies, involving nearly 150,000 patients, found that the overall survival rate from out-of-hospital cardiac arrest had barely changed in thirty years. It was 7.6 percent.
Bystander-initiated CPR can increase these odds to 10%. Survival after CPR for cardiac arrest in hospital is somewhat better, but still only approx. 17%. The numbers get even worse with age. A study in Sweden found that survival after out-of-hospital CPR dropped from 6.7% for patients in their 70s to just 2.4% for those over 90. Chronic disease also matters. One study found that less than 2% of patients with cancer or heart, lung, or liver disease were resuscitated with CPR and survived for six months.
But this is life or death – even if the odds are bleak, what’s the harm in trying if someone wants to live? The damage, as it turns out, can be significant. Chest compressions are often physically, literally, harmful. “Fractured or cracked ribs are the most common complication,” wrote the original Hopkins researchers, but the procedure can also cause pulmonary hemorrhage, liver damage, and broken sternum. If your heart is revived, you must contend with potential damage.
A rare but particularly terrible effect of CPR is called CPR-induced consciousness: chest compressions circulate enough blood to the brain to wake the patient in cardiac arrest, who may then experience ribs popping, needles entering the skin, a breathing tube going through the larynx. .
The traumatic nature of CPR may be why as many as half of patients who survive wish they had not received it, even if they lived.
It’s not just a matter of life or death, whether you survive, but quality of life. The damage sustained from the resuscitation can sometimes mean that a patient will never return to their former self. Two studies found that only 20-40% of elderly patients who survive CPR were able to function independently; others found somewhat better recovery rates.
An even bigger quality of life problem is brain damage. When heart activity stops, the brain begins to die within minutes, while the rest of the body takes longer. Doctors are often able to restart a heart only to find that the brain has died. Approximately 30% of in-hospital cardiac arrest survivors will have significant neurological disability.
Again, older patients fare worse. Only 2% of survivors over 85 escape significant brain damage, according to a study.
CPR can be harmful not only to patients but also to medical providers. In 2021, a study found that 60% of providers experienced moral distress from futile resuscitations, and that these experiences were associated with burnout. Another study linked intrusive memories and emotional exhaustion to difficult resuscitations. Holland Kaplan, a physician and bioethicist, told me that “the bad experiences far more than the good ones, unfortunately.”
She has written about performing chest compressions on a frail, elderly patient and feeling the ribs crack like twigs. She found herself wishing she “held his hand in his last dying moments, instead of crushing his sternum.” She told me she’s had nightmares about it. She described noticing his eyes, which were open, while performing CPR. Blood gushed out of his endotracheal tube with each compression.
“I felt like I was hurting him,” she told me. “I felt he deserved a more dignified death.” It is no wonder that many doctors are not fond of CPR, and choose not to do it themselves.
The true purpose of CPR is to “bridge the person to an intervention,” Jason Tanguay, an emergency physician, told me. “If they can’t get it, or it isn’t, what does it accomplish?” This is the crucial insight that doctors have and most others do not. CPR is a bridge, nothing more. Sometimes it spans the distance between life and death, if the cause can be quickly reversed, and if the patient is quite young and relatively healthy. But for many, the distance is too great. “That the act of resuscitation in itself cannot be expected to cure the provoking disease,” the Hopkins researchers wrote in 1961.
A patient with terminal cancer who is resuscitated will still have terminal cancer. In such cases, the most humane approach may be to alleviate the pain of the dying process, rather than to build a bridge to nowhere.
How can doctors help patients make these choices in advance? Part of that is education. Studies have found that half of patients changed their wishes when they learned the true survival rates of CPR, or after watching a video depicting the reality of CPR.
Another part is communication. According to a survey, 92% of Americans believe it is important to discuss end-of-life care, but only 32% have done so. Doctors (or patients) should initiate these conversations early, especially for those who are elderly or have chronic medical problems, so that their wishes are known in advance if they go into cardiac arrest.
Language is also important. Doctors often ask if patients “want everything done” if their heart stops. But it places a burden on patients and families. “Who wants to feel like they don’t want everything done for their loved one?” says Kaplan. Instead, if CPR is likely to be futile, doctors might recommend “allow natural death” rather than “do not resuscitate,” suggests Ellen Goodman, director of a nonprofit organization that encourages end-of-life conversations.
“Give people something to say yes to,” she told me. Doctors have the knowledge and experience to guide patients in the choice of measures they can benefit from, reject those that can harm, and adapt interventions according to their wishes and values. The most important thing, instead of always taking action, is to ask.
Clayton Dalton is a writer in New Mexico, where he works as an emergency physician.