Hospitals Hold Few Miracles and Many Dangers for Frail Older People

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Working at a community hospital in an economically challenged area can be difficult. The resources of a large teaching hospital are not available to us here. But these hospitals are where I feel most comfortable. I want to know that my coming to work makes a real difference for patients that I see. But lately, coming to work is a struggle. Frequently during the day, I feel that I am adding to the suffering of vulnerable people rather than alleviating it. 

One of the responsibilities of a nurse anesthetist* is to respond to emergency codes in the hospital when a patient's breathing or heart rate is not adequate. My role in a code is to manage the airway. Usually, that requires inserting a breathing tube and attaching that tube to a ventilator to breathe for the patient. I have done this for countless emergency situations over the years. More and more, it is weighing on my conscience. Here's why:

The plain fact is that for the vast majority of patients that I see, a code simply will not work. It becomes a futile almost brutal attempt to prevent that which cannot be stopped. We have all seen the dramatic rescue watching a hospital show on television; a patient's heart stops and a doctor or nurse starts CPR while another one grabs the paddles and calls "CLEAR!". They shock the patient's chest, everyone stops and looks at the monitor and ZAPPO, there is a restored heartbeat and the patient is saved. He is pulled back from the brink of death and goes on to live a normal life. I have seen this happen, but only when the patient is relatively young (under 65 years old), relatively healthy (no chronic serious medical problems) and has had CPR started almost immediately after having a heart arrhythmia. I can honestly remember only a handful of times this ideal situation presented itself. For everyone else, the picture is much more ominous. 

Most of the code situations that I am called into are for people over the age of 70. These are people with serious medical problems; kidney failure, cancer, pneumonia and dementia. Very often there are a combination of these illnesses in the same patient. And the simple fact is that for these people the code will not result in a positive outcome. If the goal in calling the code is to have these patients live to be discharged from the hospital, that goal is not likely to be met. 

Research has shown that in the best of circumstances, the odds that a patient will live to leave the hospital after having CPR is 17%. Seventeen of every one hundred people will survive long enough to be discharged either to home or to a nursing home. But those 17 of every 100 represent the best case scenarios. When we look at the research regarding the specifics for age and health conditions, the picture becomes much darker. (1)

For people over the age of 75, the odds are less than 2% will survive. People who need help with dressing, eating, bathing  or going to the toilet have a less than 5% chance and those with metastatic cancer less than 2% chance. When you combine any of these factors there is a dramatically reduced odds of survival. For patients with advanced dementia especially, there is reason to believe that performing CPR will not extend their lives, even when their heart beat is restored, they typically will die in the Intensive Care Unit during the same hospitalization. (2)

These patients represent some of the most vulnerable people in the hospital and yet they are not receiving the care that they need. The healthcare system has many technologies and medications that we can implement in our efforts to improve the health of patients. Unfortunately, this has led us to a system that is terrible at acknowledging its limitations. We simply cannot prolong life indefinitely, and we should be letting patients and their families in on that reality. There is not a lack of research in this area. There are many studies that show that patients want to know what their prognosis is, they want to know what lies ahead. And while no one can say with 100% certainty, we can give our expert opinion based on the facts that are readily available. 

Do not let yourself or your loved ones go another day without thinking about healthcare goals. How is it that you want the last days, months and years of your life to be lived? What are your priorities? Speak with one another and with your healthcare providers so that your goals are well understood. 



*Nurse anesthetist: Certified registered nurse anesthetists are advanced practice nurses who safely provide more than 40 million anesthetics for surgical, obstetrical and trauma care each year in the United States. They administer every type of anesthetic, work in every type of practice setting and provide care for every type of operation or procedure.

References: (1.) Mark H Ebell, Anna M Afonso; Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis, Family Practice, Volume 28, Issue 5, 1 October 2011, Pages 505–515, 

(2.) Ladislav Volicer. End Of Life Care for People with Dementia in Residential Care Settings.