Humanity has long sought to influence the course of death. Only in the last half century have we been able to postpone death by restarting a stopped heart. As a practicing paramedic, I have developed an insider’s view of sudden death and what happens at the end-of-life.
Sudden cardiac arrest occurs an estimated 295,000 times each year in the United States. Until 1960, there was no effective treatment for cardiac arrest and life ended at the instant the heart stopped. However, with the advent of cardiopulmonary resuscitation (CPR), automated external defibrillators (AED), well designed emergency medical service systems, and advances in cardiac care in hospitals, there is now an 8.5% chance that a person who suffers a sudden cardiac arrest will survive to live a life similar to the one they had prior to collapse.
Are you surprised that the success rate is that low? Perhaps that’s because on television, 75% of patients in cardiac arrest survive. Happy endings make for better ratings, but they cloud the perception of the end of life and may encourage us to pursue resuscitation when we should let death take its course.
CPR only works if it’s started quickly—take the short course. If a bystander witnesses a cardiac arrest and swiftly performs CPR and/or uses an AED, the survival rate rises from 8.5% to about a third. Every minute that CPR is delayed, the chance of survival drops by roughly 10 percent. After 8 minutes of cardiac arrest without CPR, the chance of survival is nearly zero.
To help reduce death from sudden cardiac arrest, everyone should take two minutes to learn the most important aspects of CPR by watching one of these American Heart Association videos – the serious version or the funny version. As these “hands only” videos show, keeping the blood pumping and calling 911 are the most important parts. Helping the victim breathe matters only after several minutes have elapsed.
Invest 4 hours in preparation to save a life. The class to become certified in performing CPR and using an AED is only 4 hours long – about the length of time of a round of golf or dinner and a movie. The American Heart Association, the American Red Cross, the National Safety Council and other organizations offer these courses on a regular basis. Once you are certified in CPR you are qualified to use the AEDs that you often see hanging in public places.
Do you want to be resuscitated? While CPR can be miraculous for some, the ability of modern medicine to keep our bodies alive has a dark side. The procedure can be undignified, look painful to an observer and result in a stay in the intensive care unit before dying. Cardiac arrest is one way our bodies signal the end. And it can be a merciful end.
We all need to make plans for the end of our lives. “No pumpkin pie, until you tell me how you want to die,” Dr. Patricia Bomba tells her family each Thanksgiving. Vice President and Medical Director of Geriatrics at Excellus BC/BS and a tireless advocate for issues regarding end-of-life care, Bomba notes that the best time to have a discussion about end-of-life care is when family members are healthy and relaxed, not while standing next to a hospital bed with a critically ill loved one or answering the door for paramedics.
Take the time to complete a health care proxy and a living will to document your wishes regarding healthcare. These documents provide the necessary direction for people who will be caring for you if you can’t speak for yourself. The documents can be completed quickly and easily in a matter of minutes using the website doyourproxy.org without need for a notary or attorney.
Take one more step if death seems likely to occur within a year. With family involved, work with the patient’s physician to create medical orders that follow his or her wishes for end-of-life care. The Physician Orders for Life Sustaining Treatment (POLST) paradigm provides the framework for this conversation and allows for the patient’s wishes to be clearly documented in medical orders for his or her care.
Only specific orders can be followed by non-physicians, such as nurses and EMTs. An important benefit of completing a POLST (or similar form) is that the orders can be followed by all healthcare providers (including EMTs and paramedics) while living wills and health care proxy forms cannot be used to prevent CPR outside of the hospital. The discussion of end-of-life choices is never easy, but there are numerous benefits to having this conversation. The website compassionandsupport.org provides numerous resources to assist the public and providers to have thoughtful conversations on these topics.
Death is never an easy topic. We have a chance to improve the quality and length of life of our family members and associates by learning CPR. And we can improve the quality of the end-of-life by thoughtful advance care planning that includes those we love.
Out-of-Hospital Cardiac Arrest Surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010, Surveillance Summaries, July 29, 2011 / 60(SS08);1-19 http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6008a1.htm
Cardiopulmonary Resuscitation on Television — Miracles and Misinformation, Susan J. Diem, M.D., M.P.H., John D. Lantos, M.D., and James A. Tulsky, M.D., N Engl J Med 1996; 334:1578-1582,June 13, 1996, http://www.nejm.org/doi/full/10.1056/NEJM199606133342406
POLST: An improvement over traditional advance directives. Patricia Bomba, Marian Kemp, and Judith Black. Cleveland Clinic Journal of Medicine 2012; 79(7):457-464; doi:10.3949/ccjm.79a.11098.http://www.ccjm.org/content/79/7/457.full