When CPR becomes DNR

Practical CPR survivability factors

Metabolic Reserve

• This is all about your ability to withstand injury, illness or a pause in your metabolic processes caused by a code.  This can be divided into two components that you can guess at during the code.
  • Age. The compliance of the lungs, stiffness of blood vessels, ability for the cells to heal are all components of age and they all decline with ae. It does not mean just because a patient is older you call it simply based on age alone but it is a factor that older patients are less likely to survive. 
  • Comorbidities. The sicker you are the harder it is for your body to juggle all the things wrong and bounceback. So the more chronic illness the less a body can handle a code, which is unfortunate multiple chronic illnesses worsening could be the cause for the code in teh first place.  I want to mention this in an independent risk factor and many providers know this is correlated with age it isn’t always. For example:  A 85yo with has been in relatively healthy shape and taking their medicaitons is much higher likelihood to return vs. and 65yo obese, diabetic with CHF and kidney transplant and only intermittently taking medications.  

Time down.

• So think about the difference in, If the arrest was witnessed vs if they were found cold in their apartment can balance or change the results. You can imagine that “found down” patients fare worse whereas if it was witnessed it is always a better chance. How long the brain or other organs has been without oxygen matters. It matters how hands on whoever got to the scene first was (this could be EMS or family or floor nurse) Did they start compressions immediately or just stare? Did they do good compressions? Did they intubate or bag? Did they attempt an IV and give meds or skip that step and bring em in? It all matters. 

Response to therapies.

• If there was a ROSC or if the patient’s heart changes rhythms and can be shocked or if there is any change or response – there is a slightly higher chance of recovery. I will usually keep trying at least 2-3 more rounds or until the next pulse check to see if more changes happen.
  There are a few ways to check for response to therapies,you can look at the end title CO2, you want it above 10-15 provided pt has been intubated. And there are a few others but the biggest one being cardiac motion on bedside US. If there is no motion at all, it becomes very obvious that there is no hope. If the heart is moving even a little, its harder to say its medically futile. Studies done on this topic are few and far between but there has been a consensus reached that 20 minutes of straight asystole in not survivable even with good compressions. And remember we count bystander CPR, paramedic or EMS CPR and ER CPR. So if the person was found in asystole with no response and got to me after 30 minutes of CPR, I will put bedside US on the chest, if still no motion- I call it. Now this has come under some question lately and once study in 2011 said that lack of cardiac motion was less of an indicator than say ROSC for example, but I haven’t been convinced yet. 

Post-Code Experience

Art of talking to families. 

1. don’t take their reaction personally but bring someone with you.
2. speak to them as if this was your best friend’s family. Don’t use big words or overload with a bunch of information or vocabulary. Don’t tell them a long story or how it all went down play by play. Be human and respond to them as they respond to you. Don’t hug or touch everyone, let them dictate the tone.
3. be clear: use the word “died” or “gone” NOT “went to heaven” or “is in a better place”
4. get to the point. They know why you are in the room, deliver the news promptly. If you ask questions first, it encourages false hope that the information they give you will change the outcome.
5.  Give them space and time to have their reaction. 

Offering to let them say goodbye

Remember that there are lots of legality around dead bodies, because many bodies are considered crime scenes we are not so we are not allowed to take out the tubes and IVs and such. So we have to prepare families for what they will see. Usually the nurses do a good job cleaning up the aftermath of the code but its also important to think about how soon after the code you want the family member to see the patient. If its not time, do not offer. After death, even with the heart stopped, some corpses have  “agonal breathing” which is very dramatic and looks like they are gasping for breath. This can happen for around 5 minutes and is the last few cells of the brainstem dying. Many family members can’t handle seeing the patient like that, I struggle with this as well. I will often tell them to wait a few minutes. Some ICUs will even push morphine or ativan and do a few chest compressions to circulate the medication to suppress these movements. It is important for you to know that these agonal breaths are NOT hope that the patient is not dead. Unfortunately. But it can be very hard to explain this to desperate family members.

Organ/Tissue Donation

Other things to know about talking to the family is that providers are not allowed to discuss organ or tissue donation in any way. Do not even mention it. If asked, get someone else usually the social worker or charge nurse to help. This came about because of the myth that doctors don’t work as hard to get patient’s back if they are organ donors- frankly this is laughable because at least 85% of the time I don’t even know this patient’s name much less if they are an organ donor. However, you should know a few things about this process. Organ donation candidates have to be in pristine condition so it can’t be an alcoholic’s liver or even their kidneys, organ donation doesn’t happen as much in the ER as it does inthe ICU because its usually considered primarily in patients with brain death while their other organs are still working. Dead organs, like those in codes who haven’t had the best perfusion are not candidates. However, tissue donation such as cornea, bone, and ligament or tendon are often taken after the person has died- so it is possible for tissue donation after a code. And I’m not allowed to be involved much more than that.

The Funeral Home Decision

Typically the body goes to the morgue for storage until decisions are made. The final destination of the body is the funeral home. And which funeral home is the only decision the family needs to make with any kind of timeliness- so if they need to busy themselves, assign them this task. You should also know that if a body needs to cross state lines, again don’t know much about it but funeral homes can help the family if that is needed.  All other choices can be decided days later.

Death Note & Death Certificates

Now lets get back to our job and briefly talk about those two documents. The first is a death note for the hospital medical chart. It must list time of death in military time, medications given and the course of events that took place, think bullet point play by play of the code. Many hospitals will have a template for this. It needs to be filed quickly and is best to do while stillfresh in your mind.  The second piece is the death certificate. This can be done by the patient’s PCP however, will often fall to whoever ran the code. This is a legal document rather than medical. It is a pain in the butt because it is harder to fill out!! This is because you have to fill out a multi-tier cause of death, to see one I’ve included a sample one in the episode webpage. And the legal cause of death is different than medical cause of death.

 For example you are not allowed to write “cardiac arrest or cardiopulmonary arrest or respiratory arrest” Which is VERY annoying. I finally had my pathology friend explain it to me. Its because heart stopping or arrest is the mechanism of death but its not the CAUSE of death. So a better answer would be cardiomyopathy of unknown etiology or pulmonary embolus due to atrial fibrillation due to congestive heart failure due to diabetes and hypertension. 

5 legal causes of death:

• Natural
• Homicide
• Suicide
• Undetermined
• Accident

Disease processes will all fall under “died of natural causes.” 

Autopsy

Any death deemed not natural legally is bound for autopsy. In the US, each state and county sets the rules and requirements for the circumstances qualify for autopsy. Ultimately, The decision lies with the county coroner who is an elected official and that’s why these decisions are vary. Usually if there is an uncertainty, their office is contacted and they decide. If a family is requesting an autopsy, even for a natural death, this can still be arranged but usually costs extra money. . The good news is after the death, there is time to decide. It doesn’t have to be decided right then. 

Other great sources: 

LITFL: Cessation of CPR

When do you stop resuscitation

Ethics of Calling Codes: how long is long enough

Filling out Death Certificate Practice

Cause of Legal Death Fact Sheet