Opportunities and Risks of Resuscitation Attempts in Nursing Homes: Facts for Nursing Home Residents and Caregivers
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Background: Data supporting decision-making regarding cardiopulmonary resuscitation (CPR) in German nursing homes is insufficient.
Methods: A retrospective evaluation of pre-hospital CPR was carried out with data from the German Resuscitation Registry (Deutsches Reanimationsregister) for the years 2011–2018. Patients under age 65 were excluded, as were patients from districts in which long-term data was available for less than 60% of patients. Subgroups were analyzed based on age and certain prehospital situations; patients treated outside nursing homes were used for comparison.
Results: The study group consisted of 2900 patients, whose mean age was 83.7 years (standard deviation, 7.5 years). 1766 (60.9%) were women and 1134 (39.1%) were men. 118 patients (4.0%) were discharged alive, including 64 (2.2%) with a cerebral performance category (CPC) of 1 or 2, 30 (1.0%) with an unknown CPC, and 24 (0.8%) with a CPC of 3 or 4. 902 patients (31.1%) died in the hospital, including five (0.2%) who died more than 30 days after resuscitation, 279 (9.6%) between 24 hours and 30 days, and 618 (21.3%) within 24 hours. 1880 patients (64.8%) died at the site of attempted resuscitation. In 1056 cases (36.4%), CPR was initiated before the arrival of the emergency medical services. In the “initially shockable” subgroup, 13 of 208 patients (6.3%) were discharged alive with a CPC of 1 or 2.
Conclusion: CPR can lead to a good neurological outcome in rare cases even when carried out in a nursing home. The large percentage of CPR attempts that were initiated only after a delay indicates that nursing home staff may often be uncertain how to proceed. Uncertainty among caregivers points to a potential for advance care planning.
An attempt at cardiopulmonary resuscitation (CPR) represents an opportunity to save the life of a patient with cardiac arrest. The likelihood of being discharged alive after CPR in out of hospital cardiac arrest (OHCA) is on the order of 10%; the majority of survivors make a good recovery (1, 2, 3, 4, 5). Severe chronic comorbidity and especially advanced frailty are thought to predict a lower than average success rate of intensive care measures (6). It is therefore not surprising that studies from various countries state the chance of being discharged alive after CPR at around 2% for residents of nursing homes (4, 7, 8, 9).
These success rates may appear poor, but to date they have not been considered so low that resuscitation should categorically not be attempted in nursing home residents. Precisely in the case of CPR such a concept of “futility” is rejected, particularly because it implies hidden value judgments (10, 11). On the other hand, always attempting resuscitation in nursing home residents would ignore the fact that many of them do not want to submit themselves to the burdens and risks associated with CPR (12 –14). Rather, the preference of well-informed patients, stated in advance, should be guiding the decisioin to attempt CPR. Observation of the patient’s wishes is expressed by consistent adherence to any relevant advance directives, the formulation of which requires correct information and communication (15, 16).
This is where advance care planning (ACP) steps in. ACP concepts aim to ensure the systematic availability of and adherence to valid expressions of treatment preferences that have been prepared in advance (17, 18, 19). In Germany, § 132g of the German Social Code V of 2015, enables facilities for the care of the elderly to offer their residents the guided discussions necessary for ACP at the expense of their statutory health insurance fund. A new extra-budgetary category was created in the official doctors’ fee scale (EBM) to cover the participation of the patient’s primary care physician (20).
Reliable and comprehensibly presented facts about the chances and risks of CPR are the foundation of an ACP conversation adequately enabling the patient to make his or her advance decision. A conversation communicating the risks should present the potential benefits and harms realistically and in absolute numbers in terms of patient-relevant outcomes (21). Fact boxes are considered an effective instrument for conveying such information (22). Little is known, however, about the success and the consequences of resuscitation attempts in German nursing homes. We therefore decided to evaluate recent data of the results of attempted resuscitations in nursing homes in terms of patient-relevant outcomes and to present the information in fact boxes that can be used as a basis for discussions of ACP.
Data on prehospital resuscitation attempts were obtained from the German Resuscitation Registry and retrospectively analyzed for patient-relevant outcomes. This registry was established in 2007 by the German Society of Anaesthesiology and Intensive Care Medicine as a comprehensive quality management instrument to quantify and continuously improve the success of treatment (23). We included CPR carried out after the publication of the resuscitation guidelines of the European Resuscitation Councils in 2010, i.e., in the calendar years 2011 to 2018. Districts for which less than 60% of long-term data were available were excluded. The study group comprised all patients at least 65 years of age who received CPR in a nursing home and was divided into two subgroups: the “oldest old,” i.e., those over 85, and the “younger old,” aged 65 to 84 (24). Subgroups were also analyzed for the two situations “witnessed arrest” and “initially shockable.” A comparison group was formed of patients aged 18 years or more with CPR at other locations during the same period, subdivided into ages 18 to 64, 65 to 84, and 85 or over. The groups are depicted in Figure 1.
Established endpoints from the resuscitation registry were employed as study endpoints (25, 26). This direct use of the endpoints offers a description of the outcomes and avoids the need for interpretation. This enables personal assessment by or on behalf of the person concerned. Subjective estimation of whether an outcome is desirable, acceptable, or unacceptable has to be on an individual basis. The following endpoints were evaluated:
- Discharged alive with cerebral performance category (CPC) 1 or 2
- Discharged alive with unknown CPC
- Discharged alive with CPC 3 or 4
- Death in hospital more than 30 days after CPR
- Death in hospital between 24 hours and 30 days after CPR
- Death in hospital less than 24 hours after CPR
- Death without transport to hospital
These individual study endpoints each include a certain spectrum of outcomes. In persons discharged from the hospital alive, neurological function is assessed in terms of CPC and documented in anonymized form in the German Resuscitation Registry. The CPC scores are as follows: 1, good cerebral function (able to work); 2, moderate cerebral disability (independent in activities of daily life); 3, severe cerebral disability (dependent on assistance); 4, coma; 5, death. In different districts, various procedures are used to determine the CPC for the purposes of the resuscitation registry.
An evaluation by year was compiled for the frequency of the endpoints, the number of cases, patient age and sex, the proportions of patients whose collapse was observed or who were initially shockable, and the frequency of CPR before arrival of the emergency rescue services.
Graphical illustration of the study group, comparison group, and subgroups took the form of fact boxes, each with a block of 100 human figures as symbol (22, 27). The software Microsoft Excel (version 2016) was used for data processing and for visualization of the percentage distribution of the different outcomes.
A total of 31 680 cases were documented in districts for which at least 60% of data on subsequent care were available. After exclusion of CPR in places other than nursing homes and patients under 65 years of age, 2900 cases (9.2%) were included in the study group. The mean age was 83.7 years (standard deviation ± 7.5 years); 1134 patients (39.1%) were male, 1766 (60.9%) female.
The Table shows the patient characteristics and CPR parameters for the study and comparison groups as a whole and for the respective subgroups by age and location. The outcome distributions are given. In the study group, 118 patients (4.0%) reached one of the “discharged alive” endpoints, 64 (2.2%) with CPC 1 or 2, 30 (1.0%) with unknown CPC, and 24 (0.8%) with CPC 3 or 4. Of the 902 patients (31.1%) who died in the hospital, 5 (0.2%) died after day 30, 279 (9.6%) between 24 hours and 30 days, and 618 (21.3%) within 24 hours after transport to hospital. Death occurred at the place where CPR was performed in 1880 cases (64.8%). In 1056 patients (36.4%), CPR was started before the arrival of emergency medical services. The subgroups “collapse observed” and “initial cardiac rhythm shockable” comprised 1224 patients (42.2%) and 208 patients (7.2%), respectively. Figure 2 shows the distribution of the endpoints in the form of a fact box with percentages rounded to whole numbers. The year-on-year trend of the endpoints is depicted in Figure 3. The eTable presents the patient characteristics and CPR parameters for each individual year.
The “younger old” (65 to 84 years) and “oldest old” (85 years and over) age groups comprised 1514 and 1386 patients respectively. The fact boxes in eFigures 1a–3c illustrate the distributions of the outcomes in the subgroups.
The comparison group of patients at least 18 years of age who underwent CPR at locations other than nursing homes embraced 27 992 persons. Of these, 3378 (12.1%) were “oldest old” (85 years and over), 14 363 (51.3%) were “younger old” (65 to 84 years), and 10 251 (36.6%) were adults aged 18 to 64 years. Figure 4 illustrates the distribution of the outcomes in the comparison group as a whole.
This study reports different outcomes after attempted resuscitation in German nursing homes and is the first publication to present the available patient-relevant endpoints in accessible form to residents, their relatives, carers, and caregivers. This is achieved by the use of fact boxes to convey the findings. Preparation of data prepared in this way forms an important basis for the urgently warranted empowerment of nursing home residents or their representatives to make their own decisions about future CPR.
The year-on-year results, as presented in Figure 3, permit no statements about the trends in the frequency of CPR in nursing homes. The growth in the number of cases from year to year (eTable) can be explained by increasing use of the German Resuscitation Registry. The annualized data show changes in the frequency of various outcomes, but no relevant trend. The study period therefore allows conclusions about the current situation in German nursing homes. Representativeness is limited by several factors. The data of the German Resuscitation Registry derive from districts with a total population of around 31 million (5). The exclusion of districts with less than 60% long-term data reduces the size of this sample and simultaneously limits the potential bias from selection of the patients who were tracked. However, different circumstances prevail in different nursing homes. There are considerable differences even in access to resuscitation. It is known that the incidence of CPR varies among nursing homes. In the course of a year in one German city, for example, CPR was carried out in 11 nursing homes, but in the other 19 nursing homes no resuscitation attempts were made (28). These differing frequencies of CPR can be interpreted as indicating overprovision and underprovision. Similar differences probably exist regarding decisions during CPR and subsequent care. Instead of potentially implicit standing instructions that CPR categorically should be attempted or omitted in nursing home residents, patient autonomy requires that residents themselves have the opportunity to make an informed advance decision on what should be done in the event of a cardiac arrest (16). In this regard, fact-based ACP has been possible since 2015 owing to the provisions of § 132g of the German Social Code V, with the costs covered by statutory health insurance (18, 20).
For personal assessment of the possible outcomes after cardiac arrest by the person making the advance plan, the available information must be interpreted individually in the context of patient autonomy. Data on wellbeing and quality of life, defined in various ways, have been published for CPR in places other than nursing homes (1, 2, 3, 29), but there appears to be no corresponding information on CPR in German nursing homes. The small number of publications from other countries leave a lot of room for personal interpretation. Thirty years ago, single-center retrospective studies of resuscitation procedures in nursing homes in the USA focussed on the endpoint “discharged alive” (30, 31, 32). In a study of CPR in 1907 French nursing home residents during the period July 2011 to September 2015, 1.4% were discharged from the hospital alive with CPC 1 or 2 (9). CPC 1 and 2 are often amalgamated and described as “good neurological outcome” (25, 26, 33). In Australia, 2.2% of 2575 nursing home residents were discharged from the hospital alive between 2010 and 2016. In contrast to CPR carried out in places other than nursing homes, none of these patients had achieved a good functional recovery 12 months later (4). The data from other countries are compatible with the results of our present study. In the present study, these endpoints were achieved somewhat more frequently, with 4% discharged alive overall and 2.2% with CPC 1 or 2. More specific endpoints that might convey a clearer impression of patients’ status after CPR in nursing homes have not been described in any study published to date. In the absence of more valid alternatives, our study offers the endpoint “discharged alive with CPC 1 or 2” as surrogate for a potentially desirable outcome. The endpoint “discharged alive with CPC 3 or 4”, covering a wide spectrum of states from conscious life dependent on assistance to coma, is the one that best reflects the outcomes which the majority of persons in Germany who do not live in nursing homes want to avoid for themselves (12). The “death in the hospital” endpoints correspond to various courses of treatment. The longer the survival time, the more likely it becomes that the stipulated or assumed will can be reliably established and the greater chance there is of the patient regaining consciousness. The endpoint “death in the hospital within 24 hours” includes persons who were transported to hospital while receiving cardiac massage with no spontaneous heartbeat, others whose heart was beating unassisted but who died unconscious or under sedation in intensive care, and a small number who regained consciousness before dying. The study endpoint “death without transport to hospital” stands for treatment of an unconscious patient with chest compressions and other intensive care measures for less than an hour until death occurred.
Figure 2 shows that “discharged alive with CPC 1 or 2” was uncommon after CPR in nursing homes and “discharged alive with CPC 3 or 4” even rarer. The majority of resuscitation attempts ended in “death without transport to hospital.” Only a minority of patients were transported to the hospital, and most of them died within 24 hours. The communication of the opportunities and risks associated with attempted resuscitation is aided by the use of fact boxes (22). For the individual perception of an outcome as opportunity or risk, a professionally guided discussion in terms of ACP is important (17, 18). Comparing the fact boxes in Figure 2 and Figure 4, one sees that “discharged alive with CPC 1 or 2” resulted more frequently when CPR was performed in locations other than nursing homes. Correspondingly, “discharged alive with CPC 3 or 4” and “death without transport to hospital” were found less often after CPR outside of nursing homes. In these cases, transport to hospital occurred more frequently and survival there was longer. Comparisons of this kind can be useful in guided ACP discussions. The differences may be explained by higher morbidity and higher biological age of nursing home residents, because the survival time after becoming dependent on care is relatively homogeneous in relation to age (34). It is important to compare the different CPR scenarios. Figure 2 and eFigures 1a, b show that the pattern of outcome shifts away from “death without transport to hospital” towards “discharged alive with CPC 3 or 4” both in cases of observed collapse and—more pronounced—in persons with an initially shockable rhythm. This finding is compatible with historic data from the USA, recent reports from Denmark, and the Cardiac Arrest Survival Score, which is also based on data from the German Resuscitation Registry (8, 30, 35). The subgroups “oldest old” and “younger old” were intended to enable recognition of age-specific features. The findings are presented in the Table and in eFigures 2a–3c. The differences in these subgroups resemble those in the study group as a whole.
If an advance directive is absent or unclearly formulated, nursing home staff, emergency rescue service personnel, and those involved in subsequent hospital treatment are frequently confronted with the problem of having to establish and implement the presumed wishes of the patient or the precise implications of the directive in a concrete situation. In this context, decisions whether to perform or omit medical procedures should be made jointly between physician and patient (or patient’s representative) and reviewed continually during the course of treatment (36). The patient’s refusal of an indicated resuscitation attempt or the lacking prospect of a medically successful result can only be determined in the individual concrete case (10, 16). Making decisions in uncertain circumstances is a core process of medical practice (21). This applies also to ACP, which requires qualified, fact-based communication of risks to patients, their representatives, and among medical professionals.
The relevance of interdisciplinary cooperation and systematic implementation of ACP is underlined by the fact that in 63.6% of instances, the nursing home staff did not attempt resuscitation themselves, but instead alerted the emergency medical services and waited for them to start CPR when they arrived. Since any delay reduces the likelihood of successful CPR, this behavior is contradictory (23). It points to an ethical dilemma for both professions. Delayed initiation of CPR could be understood as withholding care on the part of the nursing home staff or as failure to respect patient autonomy by the rescue service personnel. It may even be that such emergency calls often are not made with the true intention that CPR should indeed be initiated, but rather to increase legal security in the absence of clear guidelines on how to act during the dying process. A crucial factor in improving this situation is ensuring the presence of valid, clearly formulated, and immediately available emergency documents as part of advance directives—as a reflection of qualified shared decision-making processes in the sense of ACP (16, 17, 18, 37). The results of our study, allowing the relevant data to be presented to the target group in comprehensible form by means of fact boxes, provide a basis for adequate risk communication in these discussion processes and when deciding between treatment options.
The principal limitations of this study on patient-relevant outcomes of CPR in nursing homes result from its retrospective design. Further register-based studies could answer other medical and epidemiological questions regarding CPR in these facilities. Prospective studies of CPR in such institutions might supply important insights for primary care at the end of life, for ACP, and for palliative medicine, thus helping to improve patient autonomy in nursing homes.
Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript received on 19 February 2020, revised version accepted on 3 June 2020
Translated from the original German by David Roseveare
Dr. med. Andreas Günther
Stadt Braunschweig, Fachbereich Feuerwehr
Eisenbütteler Str. 2, 38122 Braunschweig, Germany
Cite this as:
Günther A, Schildmann J, in der Schmitten J, Schmid S, Weidlich-Wichmann U, Fischer M: Opportunities and risks of resuscitation attempts in nursing homes—facts for nursing home residents and caregivers. Dtsch Arztebl Int 2020; 117: 757–63. DOI: 10.3238/arztebl.2020.0757
Institute for the History and Ethics of Medicine, Medical Faculty, University of Halle-Wittenberg (Saale): Prof. Dr. med. Jan Schildmann
Institute for Family Practice, Medical Faculty, University of Essen-Duisburg: Prof. Dr. med. Jürgen in der Schmitten
Fire Department, City of Braunschweig: Sybille Schmid
Faculty of Public Health Services, Ostfalia University of Applied Sciences, Campus Wolfsburg: Uta Weidlich-Wichmann
Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy, Klinik am Eichert, Alb Fils Hospitals, Göppingen: Prof. Dr. med. Matthias Fischer
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