CPR is an acronym for Cardiopulmonary Resuscitation. The American Heart Association defines CPR as follows:

Cardiopulmonary resuscitation (CPR) is a combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest.  When cardiac arrest occurs, the heart stops pumping blood.  CPR can support a small amount of blood flow to the heart and brain to “buy time” until normal heart function is restored. http://www.americanheart.org/presenter.jhtml?identifier=4479

CPR is initiated immediately by any one trained in the procedure. It could be a doctor or nurse if you are in the hospital when it occurs, or it could be a passerby if it happens when you are out in public. Typically when CPR is started in the community, 911 is also called. On arrival, the EMTs would take over and you would be transported to the hospital, where further life sustaining measures would be employed. If your heart stopped beating when you were at Daybreak, our staff (we are all certified in CPR) would initiate CPR and 911 would be called.

But CPR doesn’t have to be initiated. Some people consider the heart stopping on its own a reasonable end to life. They choose instead to be kept comfortable, with no CPR, recognizing that the likelihood of death is almost certain. These people have chosen to have their doctor complete an order for “DNR”, which means Do Not Resuscitate. Some of you have considered this issue when you completed a living will. Please understand that a living will itself does not give us permission to withhold CPR. In the state of Maryland, there is a very specific, standard form that must be completed by your doctor that tells us and Emergency Medical Services that you are not to be given CPR. Consider the fact that, unlike other life prolonging treatments, CPR must be started immediately to be most effective. There is no time to consult a legal document, or to call a family, and certainly the patient is in no position to share their opinion when unconscious.

If you make a choice Not to have CPR, you must make it in advance, discuss it with your doctor, and have your doctor complete the “Maryland Medical Orders for Life Sustaining Treatment” Form (MOLST). You must then share this order with those who you spend time with. Obviously we would want a copy here. You would want your family to know, and to have a copy close at hand in case EMS was ever called to your home. Remember, without that specific form, we (and EMS) are legally obligated to initiate CPR.

Why would someone decide NOT to have CPR? There are many things for you to consider. First, consider the physical act of CPR itself. CPR is not delicate. The person administering the chest compression must push hard enough to move the sternum (your breast bone) and make the heart pump. Even a fit athlete will suffer bruising and possibly some cracked ribs if CPR has been done. If you are petite and frail, CPR will surely cause cracked ribs and severe bruising. For some, that is an acceptable trade off, others may disagree. The choice is very personal.

Other medical conditions should also be taken in to consideration. Obviously if someone has a preexisting terminal condition, doing CPR would cause pain and suffering that is unnecessary. The more medically compromised a person is, the less likely that CPR would be effective at sustaining life. The statistics below were found on a web site promoting compassionate end of life care. (http://www.compassionandsupport.org/index.php/for_professionals/molst_training_center/cpr)

  • Survival rate of CPR on television shows: –> 66%
  • Actual in-hospital survival rates for CPR:

All hospital patients: ——————————-> 15%
Frail elders*: —————————————–> <5%
Individuals with advanced chronic illness**: -> <1%

* An older person that has troubles performing activities of daily living because of weakness or fatigue is more vulnerable to acute illness due to low activity level.

**Advanced chronic illness such as Alzheimer’s, Parkinson’s or end-stage heart, lung or kidney disease.

If you or your loved one falls in to the category of “frail elder” or “individual with advanced chronic illness” as defined above, you really need to think carefully about the CPR choice. Is the pain and trauma of CPR something you want to endure if the likelihood of survival is so poor? For some the answer will be yes, for others, no. There is no right or wrong, it is a personal choice.

If you choose not to have CPR, you are instead making a choice to have “comfort measures only” If your heart stopped beating here at Daybreak, we would make you as comfortable as possible and we would never leave your side. We would call 911, and we would share your DNR form with them. They would transport you to the hospital where a physician would determine if your heart had indeed stopped. Your family would be called to join you.

It is hard to think about death, and even harder to talk about. I urge you to take control of your own experience. Have an honest discussion with your family about your wishes, and then have that discussion with your doctor. Don’t wait for him or her to raise the issue, most don’t. Advocate for yourself and choose to face the end of life as you see fit.

Christina Forbes, LGSW from the Daybreak Newsletter 7/2010