Allowing for Natural Death – Myth & Reality

CPR refers to Cardio-Pulmonary Resuscitation and is considered a “heroic” measure which is started when a person’s heart stops in a futile attempt to revive it.  It was originally developed for the middle-aged and has indeed saved some lives.  But, how effective is it for seniors?

What is done during CPR
It is not a dignified procedure.  When a patient is found without a heartbeat (in reality, they have ‘died’), a ‘Code Blue’ is called.  Chest compressions are begun and sometimes mouth-to-mouth breathing is also started.  A monitor may be attached to see if the heart is ‘shockable’.  An IV is started to give drugs, and a tube is placed through the mouth into the windpipe so that a breathing machine can be connected.  This attempt to restore life can sometimes last for over 30 minutes.

How successful is CPR?
Myth: That CPR is a simple procedure to revive a stopped/dead heart and helps most everyone!  This is a TV-perpetuated myth as evidenced by one study which found that on three popular prime time TV shows, 75% of patients survived cardiac arrest with 67% leaving hospital. [Diem SJ, et al. NEJM 1996]
Reality: CPR is a futile procedure incompatible with a peaceful death.  Under best circumstances, only 2-17% of adults in hospital survive to be discharged and half have a worsened quality of life or are worse than before being resuscitated and regret having CPR.  [(1) Murphy DJ.  Outcomes of CPR in the elderly. Ann Intern Med. 1989; (2) Waisel DB.  The CPR-not-indicated order:  futility revisited.  Ann Intern Med. 1995.  (3) Brindley PG. Predictors of survival following in-hospital adult CPR. CMAJ 2002.  (4) Peberdy MA. CPR of adults in the hospital. Resuscitation. 2003.  (5) Swor RA. Does advanced age matter in outcomes after out-of-hospital cardiac arrest in community-dwelling adults? Acad Emerg Med. 2000.]
For those in nursing homes, it’s even worse, with no one surviving in one large survey. [(1) Gordon M. Poor outcome of on-site CPR in a multi-level geriatric facility. J Am Geriatr Soc 1993.  (2) Benkendorf R. Outcomes of cardiac arrest in the nursing home: destiny or futility? Prehosp Emerg Care. 1997. (3) AMDA Annual Meeting 2014 – How to Discuss CPR and Make a Recommendation.]

What seniors and their families prefer.
Studies reveal what patients and families prefer when they have a life-limiting disease (such as congestive heart failure, emphysema requiring daily oxygen, end-stage kidney failure, terminal cancer, AIDS, Alzheimer’s dementia).  They want honest information, to be part of the decision-making process, to be comfortable, to be listened to, and to not have the dying process prolonged.  [(1) Singer PA. Quality end-of-life care: patients’ perspectivies. JAMA. 1999 Jan 13.  (2) Steinhauser KE. Factors considered important at the end-of-life by patients, family, physicians, and other care providers. JAMA. 2000Nov 15. (3) Fried TR. Understanding the treatment preferences of seriously ill patients. NEJM 2002 Apr 4.]

Our experience confirms that older seniors (especially those in nursing homes) want to be kept comfortable and enjoy life as much as possible and do not want “heroic measures” or to be put on any machines when their heart stops.  
Unfortunately, studies suggest we don’t listen to our seniors:  in our attempt to cure the incurable and reverse death, doctors and hospitals often only add to the burden of suffering experienced.  [(1) Lynn J. Perceptions by family members of the dying experience of older and seriously ill patients. (The SUPPORT study). Ann Intern Med. 1997Jan 15.]

Why isn’t CPR effective in Seniors?
The aging process and the presence of a life-limiting disease reduce a person’s ability to recover from any major insult, such as the heart stopping; there’s no more reserve to deal with one more problem.  
For the very few that do recover, because it frequently breaks ribs, they often develop pneumonia and rarely get back to their health status before the event.  

What is an “AND” or “DNR” order?
When a person decides to not have CPR, the doctor writes an order “AND” or “DNR” – meaning “Allow Natural Death” or “Do Not Attempt Resuscitation”.   This does not mean to stop treating illnesses a person wants help with, such as pneumonia, or a heart attack, or a fractured bone.  It only means, when the heart stops don’t do CPR and don’t connect a breathing machine.

Making a Decision.
Before receiving treatments or drugs, an informed consent  requires that adequate knowledge be provided.  Understandable knowledge can counter many fears and encourage hope.  Insufficient or incorrect knowledge (such as these myths) may induce false hope or expectations and lead to futile interventions (treatment which has no real short-term nor long-term benefit) and even result in a dehumanization of eldercare – a failure to offer older people that human quality we call TLC (Tender Loving Care).
Therefore, seniors must ask themselves, “When my time comes, how do I want to leave this world?”  Few want all life-saving techniques regardless of the potential risks; most want to die a natural death.  
In choosing to focus on comfort, and a natural death, seniors often actually live longer and more comfortably.  Thus, we encourage you to have an AND order written – which means when the heart stops, we stop and let a power greater than ourselves take over.  

You are encouraged to read the other handouts also.  Your nurse or doctor would be happy to answer any questions you have.

ACP 2/16