Cardiopulmonary resuscitation or CPR is a vastly misunderstood practice. It is often featured on medical TV shows because of how dramatic the process is. I have discovered that many patients have a variety of misconceptions about CPR. I want to dedicate this article to demystifying CPR. 

CPR is the procedure that medical professionals or bystanders may use to restart someone’s heart after it has stopped beating. It was developed by the American Heart Association for this purpose. Doctors go through special training to do CPR. This is called ACLS or advanced cardiac life support. You must be re-certified every 2 years. Not all doctors have to have ACLS certification. Many primary care doctors and non critical care specialists will not have it. I keep my certification current because I perform cardiac stress testing on patients several days per month. 

CPR is started once the patient no longer has a pulse. At that point their brain and heart are no longer getting any oxygen and their organ tissue is starting to die. The most important thing at that point is to restore some circulation to your system. This is done by chest compressions. Chest compressions allow the mechanical force needed to compress the heart so that it still pumps blood. Compressions do not pump as efficiently as the heart would naturally, but it can still deliver oxygen to organ tissue while the rest of the medical team tried to restart the normal electrical rhythm to the heart. 

While compressions are going on, the medical team will administer a medication called epinephrine to help restart the heart. The team will also hook up the patient to a defibrillator to determine the heart rhythm. If the heart is in an abnormal rhythm that originates from the bottom chambers of the heart like ventricular tachycardia or ventricular fibrillation, then an electric shock from the defibrillator can restore the heart to normal rhythm. If the heart is in a normal rhythm but there is no pulse, then this is called pulseless electrical activity or PEA arrest. Shocks will not help in this situation so the medical team will try other methods. Asystole is the classic “flat line” that you see on TV. This means that there is no electrical activity in the heart and electrical shocks will not help in this situation either. 

Despite what is seen on TV or reported on billboard ads, the success rate of CPR is quite low. The average success rate of CPR started outside of the hospital is only 8-10%. The American Heart Association provides data on CPR survival rates. Data in 2014 shows that about 45% of patients who suffered cardiac arrest outside of a hospital achieved ROSC or return of spontaneous circulation. The data for in hospital cardiac arrest achieving ROSC is similar. However I do not believe that ROSC is a good measurement of CPR success in the hospital. A better measure of success is: how many of those patients survive long enough to be discharged from the hospital. Unfortunately, when a patient suffers cardiac arrest in the hospital, only 10% survive to discharge.

One of the most important things for a Wise Patient to do is to decide your code status. Your code status is your decision if you want to have CPR done or not. If you do want it then you are considered Full Code. If you decide not to have it done then you are DNR or a “Do Not Resuscitate”. It’s important to decide this ahead of time and to tell your friends and family should you need CPR. 

Doctors are charged with helping patients make a decision, but it is a very difficult discussion to have. I think patients make this decision without all the information. Doctors may hesitate to recommend DNR to patients when we think it’s appropriate. The way I see it is this: if you are young then you should be full code. I had a fraternity brother and now a current family practice doctor whose heart stopped suddenly. Luckily, he was at his friend’s house who happened to be a nurse. After 8 minutes of CPR, the paramedics arrived. They performed CPR for another 23 minutes. After 4 shocks he achieved ROSC or return of spontaneous circulation. He then required another 2 shocks en route to the hospital. He has an implantable defibrillator now and 5 years later is doing great. He is a great CPR success story. 

Not everyone is that lucky. He is young and healthy with no other medical problems. Many elderly people with multiple medical problems will not have the same outcome. The reason comes down to why the heart stopped in the first place. Though genetic testing has been negative thus far, my friend likely has an inherited heart condition that caused this. Essentially, the only thing wrong with him was his heart. If you have liver cirrhosis and kidney failure and cancer and your heart stops, then it’s likely that your heart has stopped for one of these other reasons. We can certainly try to restart your heart with CPR, but remember that CPR will not fix your liver, kidneys, or cancer. The baseline problem will remain. 

So when someone is dying from an incurable ailment, DNR is really the best choice. The reason we shouldn’t just try CPR on everyone is simple: everyone should have some say in how they die. We will all die someday, and when I do I hope it’s surrounded by loved ones in a peaceful environment. CPR is not peaceful and it can be very traumatic on family present at the time. Patients are stripped naked, families are removed from the rooms, we fracture ribs with chest compressions. The whole scene is hectic. I have performed several essentially futile CPRs on elderly or dying people that robbed family of that peaceful passing. I wish those had gone differently. I wish the family and patient had decided on DNR ahead of time. I think it’s up to us as doctors to instruct people on what CPR really is, what your expectations of CPR should be, and how to prepare for it. I hope this article has helped to do that today. Talk this over with your doctor at your next visit.