Per istam sanctan unctionem et suam piissimam misericordiam, indulgeat tibi Dominus quidquid per (visum, audtiotum, odorátum, gustum et locutiónem, tactum, gressum deliquisti.) Catholic Catechism prior to 1972

SHOCK ADVISED    Voice prompt from Automatic External Defibrillator prior to shock being delivered

A miracle happened 50 years ago. In 1960 an article was published that documented 14 people who survived what up until then was a fatal heart stoppage. The survival was facilitated by closed chest massage, the act of pressing firmly and rhythmically on the chest until a heart rate returned. In 1962, the delivery of electricity in the form of direct-current, monophasic current (defibrillation) was found to result in increased survival. Prior to that, people whose heart stopped were just dead.

Unfortunately, not all people who need chest compressions and defibrillation are created equal. If the patient’s heart is stopped because of an episode of ventricular fibrillation and the defibrillator happens to be right next to the patient, the patient has a 1 in 4 chance of walking out of the hospital as if nothing happened. If the heart has stopped for any other reason, the chances are less than 1 in 10. For every minute it takes to get the defibrillator to the patient to administer the shock, the absolute chance of survival goes down by 7%. If the first check of the cardiac rhythm reveals a type of rhythm called pulseless electrical activity (PEA), the chance of leaving the hospital through the door (as opposed to the morgue) is less than 1 in 100 and the chance of not having a significant loss of neurologic function even if you leave through the door is less than 1 in 1000. If you have an underlying disease such as metastatic cancer or renal failure, the chance of surviving an episode of cardiopulmonary arrest is often less than 1 in 100 regardless of what the initial rhythm was. For some, a death due to arrythmia might be preferable to death due to an underlying disease such as dementia or painful metastasis. Allowing patients to determine what response they would prefer should cardio-pulmonary arrest occur is made more dificult because  people really overestimate their possibility of survival should they go into cardiopulmonary arrest by a factor of 2-3 times.

So why do we continue promote this technology (CPR and ACLS) that only works for a very select group of people in very specific circumstances as a panacea for anyone who is dying? From a website describing traditional (prior to 1972) Roman Catholic beliefs, the “last rights” or Extreme Unction

is the anointing given to those who are gravely bodily ill, especially those in danger of death from bodily illness or from violence already done to the body. The effects of the Sacrament are the strengthening and comfort of the soul of the anointed one, the remission of sins and some of their temporal punishments, and the possible restoration of bodily health.

This rite was offered to all Catholics. It was considered important to receive this sacrament prior to death if one wished to ascend quickly into heaven. You will note, importantly, it was not a request specifically for divine intervention to restore bodily health (the recipient was expected to die). It was a request for forgiveness, comfort and solace. It offered solace not only to the stricken, but to the family members who shared the sick house as well in part because they were expected to participate in the service.

The scene is familiar from television shows such as ER and Grey’s Anatomy. Paramedics rush a patient into the emergency room or a nurse in an intensive care unit shouts ―code blue. Crash carts are deployed and a doctor orders a procedure ―stat, such as ―start a central line. The doctor might intubate or ―bag the patient or, more dramatically, ―shocks them by applying the paddles to the chest immediately after someone yells ―clear. A nurse yells something about ―V-Fib so the doctor orders Lidocaine and hollers, ―charge to 300! Clear! and shocks the patient again. Sometimes the patient‘s heart starts again, and because of the miracle of medical technology the patients lives, although for how much longer we rarely find out. Sometimes the efforts of the medical staff are in vain, and the doctor ―calls it. Occasionally, the doctor does not quit until the futility of the exercise is apparent, sometimes pointed out by a nurse or another doctor. ―Time of death, 2:25. A nurse or technician turns off the monitors, and the high-pitched continuous tone, which had previously been a series of rapid beeps, goes silent. The doctors and nurses leave the room and the last camera shot is the corpse on a gurney, with tubes penetrating the body and the floor littered with medical waste.

This is the metaphorical fist towards the heavens that I believe is today’s equivalent to “last rites.” The above passage was taken from a dissertation written last year that looked at the attitudes towards death of physicians and patients in a large, north-eastern hospital.  As described in  John Fox’s dissertation, physicians see death as the enemy and feel uncomfortable  discussing short-term prognoses with patients. He details situations where patients are appropriately aware that they are dying only to have their sanity questioned by their physicians. In addition, the general public has little concept of the inner workings of death in the hospital or even of the limitations of technology; thus they are hesitant to not summon the health care gods when it appears they might benefit. In short, “I’m a Catholic, please call a priest” has morphed into “I’m dying, call 911.”

Dr Fox (I presume he got his doctorate) points out that dying is a part of living and suggests we need to continue to emphasize palliation and spirituality when caring for the dying. I hope we as a profession can change our focus from curing to caring for patients who are clearly making this transition. Offering someone who will not benefit a procedure such as ACLS because we are uncomfortable having a conversation is not right. Spending billions of dollars on end-of-life procedures known to be worthless to fight an enemy (death) who is clearly going to win is not right either. I hope that as defibrillation and CPR approach 60, we are finally able to put them in their rightful place in our armamentarium. As I discussed here, having such discussions is important. Maybe one day we’ll get paid for them.

Addendum – The New England Journal of Medicine has published an editorial on this subject here which is worth a read

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