Let them die
Did you channel your inner Ken Watanabe from the Godzilla movie saying “Let them fight”, while you read this title? No? K.
That is the only relative humor you will find in this post because it goes pretty down hill from here. What was that? Already downhill you say? I’ll see you when I see you.
This blog post is about the futility of CPR. Most people who are reading this know by now that I am a proponent of CPR and resuscitation science. I’ve spent almost the entirety of my teaching career advancing Life support skills, and implementing this knowledge on patients on an everyday basis. Over these three years in emergency medicine, I’ve seen seen things that I cannot unsee and this has, on occasion, made me hyper vigilant in resuscitation scenarios. Multiple studies have shown that such behavior is akin to PTSD in soldiers returning from war and that brings us to the point of this article - the flip side of CPR.
The idea for this blog post came to me on a sunny sunday afternoon shift. A hypothetical 65 year old was brought into the emergency by bystanders in an unresponsive state. Collapsed on the sidewalk some 20 minutes ago. With no one accompanying him. Bystanders thought it would be wise to just shift him to the hospital in an auto rather than wait for 108, rightfully so. One look at the patient and we knew he was dead. Long gone. No brainstem reflxes, cold and cyanosed - this was a classic brought dead scenario. The first person I broke the news to was the bother in law who had arrived before anyone else. He took the news in, processed it while I sat next to him and looked up to me and said “My sister will not take this well”. I break bad news on a daily basis. I follow set guidelines while I’m breaking the news and I’ve even given a talk about how to do it, empathetically. But I was not ready for what was about to unfold over the next 90 minutes. The dead patients wife was brought in to the room we have for privacy and she was already crying and wailing as to what had happened to her husband. She still doesn’t know he’s dead. She did not give me a chance to speak and as I was trying to calm her and start explaining her what is happening, her brother barks out - He’s no more. In a flash, her hands were on my collar and she was at my face yelling - You cannot do this to me. It took her sometime to let go of me, but she still didn’t accept the news. I was stuck in the first stage of the 5 stages of grief with her, in that room, for the next 90 minutes.
There’s no denying that this was the worst moment of her entire life. It was my duty to stand by her and make sure she comes to terms with this hard fact, stay until she accepts it. India still doesn’t have social workers or grief counselors to handle the emotional needs of our patients and that job is being taken care of by untrained and under prepared Emergency Physicians and Intensivists who basically just wing it, in whatever they know best. I did not mind any part of her out burst or emotional response. I do not blame her for it , nor do I wish it was some one else in my place. This was the most dramatic response I’ve encountered in all my experience of dealing with bad news and emotional family members. But that is not what led to this post. When we later sat down as a team to debrief this particular event, a suggestion came up that may be we should have attempted CPR on this dead man for the sake of the family, for their satisfaction, and that ladies and gentlemen, brings us to where you are now. Too long of a back story? No. You, as doctors, are bound to face this choice and how you chose will reflect how righteous you are.
Do you perform CPR on a patient who you know is dead? Do you perform CPR on someone who has been unresponsive and pulseless for more than 5 minutes? Who is already cold and without brainstem reflexes?
To answer this question, you need to understand what the ‘successful’ revival of a patient actually means, or to put it in medical terms - what does ROSC (Return of spontaneous circulation) entail and is getting a pulse back always a good thing?
CPR and advanced resuscitation is not some magic trick that brings patients back from the dead. So lets first understand what Cardiopulmonary resuscitation does to the body. A cardiac arrest is a sudden event, an instantaneous collapse, like falling over the edge of a cliff, and these are the patients in whom CPR can make a difference. When a patient has a cardiac arrest, his or her heart has essentially stopped pumping blood and the most vital organ of them all, the brain, stops receiving blood. The Brain is extremely sensitive to this lack of circulating oxygenated blood and all it takes is one minute of absence of blood supply for the onset of permanent Hypoxic Ischemic Encephelopathy, or in lay man terms, brain death. When we resuscitate a patient, what we’re essentially trying to do is making sure that the brain receives blood supply, by pumping the stopped heart from outside, by chest compressions, while we’re simultaneously trying to figure out which one of the ten reversible causes has caused this sudden cardiac arrest and injecting drugs like Epinephrine which are hypothesized to “restart” the hearts contraction. Go on, read this paragraph again if you need to. Resuscitation is making sure the brain receives oxygenated blood while you’re figuring out how to restart the heart so it can beat on its own, or - ROSC! Makes sense?
But what if the patient’s brain is already a goner - what we in Emergency medicine call “Down time”. Remember, all it takes is a minute of lack of blood to cause permanent brain death. So lets say a patient with about 15 minutes of down time is brought to the emergency room. You checked for response, no response, you checked for pulse and breathing - nope and you went all out on him - started CPR, intubated him, went at him like there was no tomorrow. Gave him shot after shot of Epinephrine and then out of nowhere, you start feeling a pulse. Great! You got a pulse. Thats ROSC! Do you think your resuscitation is a successful one? The answer is no. Not by any means. Success is measured by how disabled this patient is going to be. 15 minutes of down time and brain is already scrambled eggs. What you basically did was bring back someone who is going to be in a vegetative state for the rest of his or her mortal life. Why did the heart restart though? that’s what chest compressions and epinephrine can do.They force the autonomous cardiac myocytes to start contracting again. But what’s the point without any brain to function? That- Brain function or neurological response - is the sole measure of success of resuscitation and that brings us to the flip side of resuscitation - Letting them Die.
That was about Down time. This piece is incomplete if I don’t talk about the very sick and the very old. A very damning article published in the Irish times started off like this - “Stop the barbaric practice of using CPR on the very old”. This article tries to reason the difference between sudden cardiac arrest and natural death. The processes in ordinary dying are quite different from cardiac arrest. Like I explained earlier A cardiac arrest is an instantaneous collapse, like falling over the edge of a cliff. In ordinary dying, usually now after a long life, from “not cardiac arrest”, there is prior deterioration over months, days, hours, minutes and seconds until finally the heart stops. Imagine for a moment the fragile body of a woman in her 90s, who has a multiplicity of chronic diseases, including dementia, after it has been subject to vigorous and unsuccessful CPR. Rib bones will have been crunched, soft tissue bruised and teeth broken.
Do you remember your oath? To do no harm. The onus is on you to ensure that the treatment is not worse than the medical condition you are trying to treat. No one knows better than doctors that death is a very real entity. It hounds every one of our patients and it is time we start recognizing when it is time.
Doctors are not cowboys. Do not swing your fancy Endotracheal tubes and bougies and resuscitation knowledge on unsuspecting families. Yes, they will beg and plead and bargain with you to try, but it is your imperative to stand your ground, to let them die.