every day across the country people come
to hospitals they come for help for
answers and because they don’t know what
else to do
while in the hospital they expect that
the ethical principles of
non-maleficence to do no harm
beneficence to do good and autonomy to
be able to make their own health care
decisions will be honored these probably
aren’t the words they use but this is
what people expect when somebody first
enters the hospital there’s a great deal
of information that needs to be gathered
in addition to the questions one might
typically expect code status is an
important piece of information
this tells the hospital what the patient
wants done in the event their heart
would stop during their hospitalization
cardiopulmonary resuscitation CPR or do
not resuscitate DNR that is the question
pretty heady stuff to be discussing when
somebody has just arrived in the
hospital and is probably anxious the
timing and quality of this discussion
varies depending on the knowledge skill
and comfort level of the person charged
with obtaining that information a few
years ago I accompanied my mom to the
hospital a sheet after she’d been seeing
in the emergency department as she was
getting settled a nurse came in to begin
collecting the needed information when
she got to this topic of code status she
said to my frail 86 year old mom who is
about this tall by that time you do want
us to heart start your heart back up if
it stops while you’re here don’t you
I truly believe that this nurse expected
the answer to that wreck question was
going to be a resounding well yes the
reasons for this are many but the one
that has my attention is the fact that
in the hospital the default rule is if
your heart stops CPR is performed it’s
the expect
to action and because it is there is
little sense of urgency to clarify code
status and the discussions regarding CPR
are often superficial not included in
the question asked my mom was what
exactly does it take to get your heart
started again what can happen during the
course of resuscitation how successful
is CPR mom was lucky she had my 29 years
of experience providing hospice care and
working in hospital ethics committees at
her side to be sure those questions got
answered most people don’t have that
kind of a resource if you’re a patient
in the hospital and your heart stops CPR
will be performed without your written
consent it’s a default rule the only
exception to this rule is if a physician
has entered a do not resuscitate order
and documented it in your medical record
in the absence of this order CPR is
performed CPR provides an intersection
of several important ethical principles
it has the potential to do great good it
also has the potential to do harm which
is why I’m suggesting that the default
rule in the hospital be reversed that
resuscitation not occur until somebody
has provided informed consent because
sometimes CPR goes awry it can cause an
injury sometimes irreparable consider
this story published on may 14th of this
year in the Daily News a 90 year old
gentleman with Parkinson’s disease was
resuscitated without his consent when
his heart stopped during surgery the
chest compressions cracked his sternum
and he was unable to breathe on his own
so a feeding tube orab breathing too was
inserted he was connected to a breathing
machine and transferred to the
hospital’s intensive care unit there a
feeding tube was inserted while staying
in ICU his memory faded his speech
became slurred but after 13 days he was
discharged to go home requiring the care
of two
family members six weeks later in severe
pain he died let me be clear I am NOT
suggesting that this rule reefer
reversal occur in emergency departments
when a patient presents in cardiac
crisis I am proposing that when somebody
is admitted to the hospital the process
to determine their code status include
informed consent informed consent is a
process hospitals have in place to
provide patients with the information
they need so they can make their own
medical decision it honors patient
autonomy there are three basic steps the
first is that the provider and the
patient have a discussion regarding the
proposed procedure it includes the
benefits the risks and potential
outcomes next the patient makes a
decision regarding that procedure that’s
in keeping with their own values and
lasts the patient has to understand the
implications of the decision they’ve
made this is all documented in the
patient’s medical record when somebody
is in the hospital informed consent is
one of the things that’s available to
them and hospitals required this for a
variety of procedures this includes
surgery chemotherapy anesthesia it’s a
long list but CPR is not on that list
yet CPR has the potential to cause
broken bones intolerable pain dependence
on technology for the remainder of
someone’s life a procedure with the
potential to cause these outcomes should
require informed consent a look at the
history of CPR provides some insight as
to how we’ve arrived at our current
default rule in the 18th century
resuscitation was considered impious and
placed on the level of like raising the
dead despite this dubious beginning for
the next 200 years we continued to try
to figure out how to bring people back
to life in 1956 mouth-to-mouth
resuscitation was invented in
69 CPR was developed and the American
Heart Association did physician
education in 1972 widespread community
education was rolled out to teach the
general public how to perform CPR in
2018 CPR is expected to raise the dead
an idea filled by television and movies
so what is successful CPR the definition
of success is the return of spontaneous
circulation the resumption of breathing
and pulse or blood pressure to achieve
this a person’s chest must be compressed
at least two inches this requires a
force of a hundred to 125 pounds even
when successful CPR doesn’t fix other
health problems a person may have so if
somebody has dementia or cancer or
diabetes or COPD any number of health
problems these remain and are often as a
survey today CPR is performed yet there
is widespread belief among the general
public that CPR is successful at least
75 percent of the time but the numbers
regarding the success rate of in
hospital CPR tell an entirely different
story the acute success rate this is the
number of attempts that result in the
return of spontaneous circulation is
about 40 percent but the number that has
the greatest impact is the survival to
discharge rate these are individuals who
survive the CPR episode and are able to
be discharged from the hospital this is
between 10 and 11 percent research has
shown the characteristics of individuals
most likely to serve to survive CPR as
you might expect these are people who
are younger they are also people whose
primary health problem is cardiac in
nature and who were functionally
independent prior to the CPR episode
even when it is successful there can be
great
personal costs associated with surviving
CPR such as brain damage a decrease in
the functional level an inability to
provide self-care requiring an
alternative living setting given these
given this information regarding the
outcomes and success of CPR I was really
concerned when I received a call a
couple years ago from the nursing home
where my dad had lived for a few months
they reported that they found him passed
out with an irregular heartbeat so they
called the ambulance to transport him to
the emergency room and then they called
me at the time I was working a couple
hours away my dad’s name was Cassius
kind of a big name for little kids to
say so his eight-year-old great
granddaughter dubbed him grandpa
grandpa casserole did not mirror the
characteristics of somebody likely to
survive CPR he was almost 99 years old
very frail and had dementia it was a
long drive to the emergency room giving
me time to wonder what was going to
happen to my dad and to think about the
ethical implications of the current
default CPR rule in hospitals there are
five primary principles of medical
ethics these are to not cause harm to do
good to use resources fairly and justly
to tell the truth and to provide
patients with information needed so they
can make their own healthcare decisions
our current default CPI rule in the
hospital does not honor these ethical
principles in the following ways it may
be inconsiderate of a person’s values
goals and definition of quality of life
it can cause physical and psychological
harm it can increase financial burdens
through hospital costs long-term care
costs and cost to caregivers associated
with lost wages out-of-pocket expenses
are not covered by Medicare or Medicaid
or insurance and additional stress and
anxiety and it can create a sense of
false hope when full disclosure
regarding the CPS process is not
provided this impacts a patient and
their family’s ability to make decisions
for the present in the future
informed consent honors all of these
ethical principles even when somebody
has been determined unable to make their
own medical decision informed consent
must be provided by their legally
designated caregiver in person or by
proxy people have the right to
self-determination to make decisions
regarding what happens to their body in
view of all of this information my
proposal is that hospitals reverse their
current default rule regarding CPR that
patients are not resuscitated unless
they have provided informed consent so
why would I make a proposal that is
probably controversial that conflicts
with hospital culture and community
expectations this change will align cpr
with other invasive hospital procedures
that require informed consent
it will provide patients and families
with information not typically available
under the current rule allowing them to
make better informed decisions and it
will it will enable patients and
families to look at all the care options
available to them and have discussions
the primary goal of cardiopulmonary
resuscitation is to prevent premature
death it is not to prolong inevitable
death is this proposal controversial and
provocative it is does it challenge the
status quo I hope it does we are in
desperate need of a cultural shift
regarding the way we consider and
communicate about the end-of-life
sometimes cultural change requires a
disc
ruptor this idea maybe the disrupter to
increase our sense of urgency to have
conversations about important
end-of-life issues with those we care
for and those we care about thank you
[Applause]
[Music] you
to hospitals they come for help for
answers and because they don’t know what
else to do
while in the hospital they expect that
the ethical principles of
non-maleficence to do no harm
beneficence to do good and autonomy to
be able to make their own health care
decisions will be honored these probably
aren’t the words they use but this is
what people expect when somebody first
enters the hospital there’s a great deal
of information that needs to be gathered
in addition to the questions one might
typically expect code status is an
important piece of information
this tells the hospital what the patient
wants done in the event their heart
would stop during their hospitalization
cardiopulmonary resuscitation CPR or do
not resuscitate DNR that is the question
pretty heady stuff to be discussing when
somebody has just arrived in the
hospital and is probably anxious the
timing and quality of this discussion
varies depending on the knowledge skill
and comfort level of the person charged
with obtaining that information a few
years ago I accompanied my mom to the
hospital a sheet after she’d been seeing
in the emergency department as she was
getting settled a nurse came in to begin
collecting the needed information when
she got to this topic of code status she
said to my frail 86 year old mom who is
about this tall by that time you do want
us to heart start your heart back up if
it stops while you’re here don’t you
I truly believe that this nurse expected
the answer to that wreck question was
going to be a resounding well yes the
reasons for this are many but the one
that has my attention is the fact that
in the hospital the default rule is if
your heart stops CPR is performed it’s
the expect
to action and because it is there is
little sense of urgency to clarify code
status and the discussions regarding CPR
are often superficial not included in
the question asked my mom was what
exactly does it take to get your heart
started again what can happen during the
course of resuscitation how successful
is CPR mom was lucky she had my 29 years
of experience providing hospice care and
working in hospital ethics committees at
her side to be sure those questions got
answered most people don’t have that
kind of a resource if you’re a patient
in the hospital and your heart stops CPR
will be performed without your written
consent it’s a default rule the only
exception to this rule is if a physician
has entered a do not resuscitate order
and documented it in your medical record
in the absence of this order CPR is
performed CPR provides an intersection
of several important ethical principles
it has the potential to do great good it
also has the potential to do harm which
is why I’m suggesting that the default
rule in the hospital be reversed that
resuscitation not occur until somebody
has provided informed consent because
sometimes CPR goes awry it can cause an
injury sometimes irreparable consider
this story published on may 14th of this
year in the Daily News a 90 year old
gentleman with Parkinson’s disease was
resuscitated without his consent when
his heart stopped during surgery the
chest compressions cracked his sternum
and he was unable to breathe on his own
so a feeding tube orab breathing too was
inserted he was connected to a breathing
machine and transferred to the
hospital’s intensive care unit there a
feeding tube was inserted while staying
in ICU his memory faded his speech
became slurred but after 13 days he was
discharged to go home requiring the care
of two
family members six weeks later in severe
pain he died let me be clear I am NOT
suggesting that this rule reefer
reversal occur in emergency departments
when a patient presents in cardiac
crisis I am proposing that when somebody
is admitted to the hospital the process
to determine their code status include
informed consent informed consent is a
process hospitals have in place to
provide patients with the information
they need so they can make their own
medical decision it honors patient
autonomy there are three basic steps the
first is that the provider and the
patient have a discussion regarding the
proposed procedure it includes the
benefits the risks and potential
outcomes next the patient makes a
decision regarding that procedure that’s
in keeping with their own values and
lasts the patient has to understand the
implications of the decision they’ve
made this is all documented in the
patient’s medical record when somebody
is in the hospital informed consent is
one of the things that’s available to
them and hospitals required this for a
variety of procedures this includes
surgery chemotherapy anesthesia it’s a
long list but CPR is not on that list
yet CPR has the potential to cause
broken bones intolerable pain dependence
on technology for the remainder of
someone’s life a procedure with the
potential to cause these outcomes should
require informed consent a look at the
history of CPR provides some insight as
to how we’ve arrived at our current
default rule in the 18th century
resuscitation was considered impious and
placed on the level of like raising the
dead despite this dubious beginning for
the next 200 years we continued to try
to figure out how to bring people back
to life in 1956 mouth-to-mouth
resuscitation was invented in
69 CPR was developed and the American
Heart Association did physician
education in 1972 widespread community
education was rolled out to teach the
general public how to perform CPR in
2018 CPR is expected to raise the dead
an idea filled by television and movies
so what is successful CPR the definition
of success is the return of spontaneous
circulation the resumption of breathing
and pulse or blood pressure to achieve
this a person’s chest must be compressed
at least two inches this requires a
force of a hundred to 125 pounds even
when successful CPR doesn’t fix other
health problems a person may have so if
somebody has dementia or cancer or
diabetes or COPD any number of health
problems these remain and are often as a
survey today CPR is performed yet there
is widespread belief among the general
public that CPR is successful at least
75 percent of the time but the numbers
regarding the success rate of in
hospital CPR tell an entirely different
story the acute success rate this is the
number of attempts that result in the
return of spontaneous circulation is
about 40 percent but the number that has
the greatest impact is the survival to
discharge rate these are individuals who
survive the CPR episode and are able to
be discharged from the hospital this is
between 10 and 11 percent research has
shown the characteristics of individuals
most likely to serve to survive CPR as
you might expect these are people who
are younger they are also people whose
primary health problem is cardiac in
nature and who were functionally
independent prior to the CPR episode
even when it is successful there can be
great
personal costs associated with surviving
CPR such as brain damage a decrease in
the functional level an inability to
provide self-care requiring an
alternative living setting given these
given this information regarding the
outcomes and success of CPR I was really
concerned when I received a call a
couple years ago from the nursing home
where my dad had lived for a few months
they reported that they found him passed
out with an irregular heartbeat so they
called the ambulance to transport him to
the emergency room and then they called
me at the time I was working a couple
hours away my dad’s name was Cassius
kind of a big name for little kids to
say so his eight-year-old great
granddaughter dubbed him grandpa
grandpa casserole did not mirror the
characteristics of somebody likely to
survive CPR he was almost 99 years old
very frail and had dementia it was a
long drive to the emergency room giving
me time to wonder what was going to
happen to my dad and to think about the
ethical implications of the current
default CPR rule in hospitals there are
five primary principles of medical
ethics these are to not cause harm to do
good to use resources fairly and justly
to tell the truth and to provide
patients with information needed so they
can make their own healthcare decisions
our current default CPI rule in the
hospital does not honor these ethical
principles in the following ways it may
be inconsiderate of a person’s values
goals and definition of quality of life
it can cause physical and psychological
harm it can increase financial burdens
through hospital costs long-term care
costs and cost to caregivers associated
with lost wages out-of-pocket expenses
are not covered by Medicare or Medicaid
or insurance and additional stress and
anxiety and it can create a sense of
false hope when full disclosure
regarding the CPS process is not
provided this impacts a patient and
their family’s ability to make decisions
for the present in the future
informed consent honors all of these
ethical principles even when somebody
has been determined unable to make their
own medical decision informed consent
must be provided by their legally
designated caregiver in person or by
proxy people have the right to
self-determination to make decisions
regarding what happens to their body in
view of all of this information my
proposal is that hospitals reverse their
current default rule regarding CPR that
patients are not resuscitated unless
they have provided informed consent so
why would I make a proposal that is
probably controversial that conflicts
with hospital culture and community
expectations this change will align cpr
with other invasive hospital procedures
that require informed consent
it will provide patients and families
with information not typically available
under the current rule allowing them to
make better informed decisions and it
will it will enable patients and
families to look at all the care options
available to them and have discussions
the primary goal of cardiopulmonary
resuscitation is to prevent premature
death it is not to prolong inevitable
death is this proposal controversial and
provocative it is does it challenge the
status quo I hope it does we are in
desperate need of a cultural shift
regarding the way we consider and
communicate about the end-of-life
sometimes cultural change requires a
disc
ruptor this idea maybe the disrupter to
increase our sense of urgency to have
conversations about important
end-of-life issues with those we care
for and those we care about thank you
[Applause]
[Music] you
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