Survival is not the only outcome measure patients need to take into account when deciding whether to undergo CPR. Quality of life following resuscitation also warrants consideration. Interestingly, research has shown that neurologic outcomes among the majority of cardiac arrest survivors are generally good.3
Approximately 86% of survivors with intact pre-arrest cerebral performance maintain it on discharge, and only a minority of survivors are eventually declared brain-dead.3 Still, there are certain peri-arrest factors that pose risk for poorer neurologic and functional outcomes. For arrest from a shockable rhythm, time to defibrillation is a key determinant.11 In patients for whom time to defibrillation is greater than two minutes, there is significantly higher risk of permanent disability following cardiac arrest.11
In the event of coma following resuscitation, particular clinical findings can be used to accurately predict poor outcome.12 The absence of pupillary reflexes, corneal reflexes, or absent or extensor motor responses three days after arrest are poor prognostic indicators.12 As a general rule, if a patient does not awaken within three days, neurologic and functional impairment can be expected.12 For those patients who do survive to hospital discharge, more than 50% ultimately will be able to be discharged home.3
However, nearly a quarter will need to be newly placed in a rehabilitation or skilled nursing facility.3
Back to the Case
The patient was admitted with hypoxia secondary to both progressive lung malignancy and COPD exacerbation. She had no advanced directives, so the admitting hospitalist, in collaboration with her oncologist, had a detailed discussion regarding her understanding of her disease progression, prognosis, and goals for her remaining time. Her questions regarding survivability of cardiac arrest were answered directly with an estimate of 5% to 10%, based on her age, comorbidities, and the presence of advanced malignancy.
After hearing this information, the patient responded, “I still want everything done.” The hospitalist acknowledged her feelings of wanting to fight on, but asked her to think about what “everything” meant to her. After taking some additional time to reflect with friends and family, the patient was clear that she wanted to continue disease-focused therapies, but did not want to be resuscitated in the event of cardiac or pulmonary arrest.
Eventually, her hypoxia improved with antibiotics, steroids, and bronchodilators. She was discharged home with follow-up in the oncology clinic for additional chemotherapy and palliative radiation.
For hospitalized adults, the average survival rate to discharge after cardiac arrest is about 17%. Many factors lower a patient’s chance of survival, including advanced age, performance status, malignancy, and presence of multiple comorbidities. TH
Dr. Neagle and Dr. Wachsberg are hospitalists and instructors in the division of hospital medicine at Northwestern University Medical Center in Chicago.
- Murphy DJ, Burrows D, Santali S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med. 1994;330(8):545-549.
- Kaldjian LC, Erekson ZD, Haberle TH, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics. 2009;35(6):338-342.
- Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58(3):297-308.
- La Puma J, Orentlicher D, Moss RJ. Advance directives on admission. Clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA. 1991;266(3):402-405.
- Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.
- Larkin GL, Copes WS, Nathanson BH, Kaye W. Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation. 2010;81(3):302-311.
- de Vos R, Koster RW, De Haan RJ, Oosting H, van der Wouw PA, Lampe-Schoenmaeckers AJ. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Arch Intern Med. 1999;159(8):845-850.
- Reisfield GM, Wallace SK, Munsell MF, Webb FJ, Alvarez ER, Wilson GR. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006;71(2):152-160.
- Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer. 2001;92(7):1905-1912.
- Chan PS, Nichol G, Krumholz HM, et al. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302(11):1195-1201.
- Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
- Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;67(2):203-210.