Commonly known as CPR, cardiopulmonary resuscitation is the process of externally supporting circulation and respiration in a person with cardiac arrest. Resuscitation measures take the form of basic cardiac life support (BCLS) and advanced cardiac life support (ACLS). Basic Cardiac Life Support is the external support of circulation and ventilation via artificial respiration, e.g., mouth-to-mouth, mouth-to-mask, mouth-to-nose, etc., and chest compressions. Advanced Cardiac Life Support includes BCLS and the use of adjunctive equipment and techniques to establish and maintain effective ventilation and circulation, to monitor the disrhythmia, to establish IV access, and to provide therapies for patients with cardiac arrest, respiratory arrest and acute myocardial infarction. Since the development of chest compressions more than thirty-five years ago, CPR techniques have not changed significantly. The 1974 standards for cardiopulmonary resuscitation described CPR as a series of medical interventions "administered to reverse unexpected cardiac or pulmonary arrest in order to prevent sudden unexpected death" (emphasis added). Thus, CPR was intended to be used with patients who were otherwise in good physiological condition.
Because it often must be administered in circumstances of an unexpected, acute life-threatening emergency where informed consent is impossible, consent for CPR is usually presumed, unless medically contraindicated or consent has already been refused through a Do-Not-Resuscitate (DNR) order or other advance directive. Since CPR may include a series of separate and distinct interventions (e.g., drugs to calm arrhythmia and relieve pain) that can also be provided independently of resuscitation efforts, the presence of a DNR does not necessarily imply that these individual interventions should not be provided. Even in the presence of a DNR, these other interventions may be appropriate and necessary. Moreover, a DNR order never means "do not treat."
Public expectations of the success of CPR are quite unrealistic and do not match the statistics. Only about 15% of hospitalized patients in whom resuscitation is attempted will survive to discharge. Numerous studies have shown virtually no survival to hospital discharge for patients with pneumonia, renal failure, acute stroke, multiple-organ failure or patients with advanced acute terminal diseases who have in-hospital arrests. Patients over 70 years of age who have sepsis or metastatic carcinoma, or whose arrest lasts more than 15 minutes, are unlikely to survive. Recent research suggests that CPR success varies from one institution to another and that the pre-arrest condition of the patient may be the most important predictor of success. [Sources: Junkerman, C and Scheidermayer, D, Practical Ethics for Students, Interns, and Residents. (Frederick, MD: University Publishing Group, 1994), 3-6. AMA Council on Ethical and Judicial Affairs, "Guidelines for CPR--Ethical Considerations in Resuscitation," JAMA 265 (1991): 1868-71. Tomlinson, B and Brody, H, "Futility and the Ethics of Resuscitation," JAMA 264 (1990): 1276-80. Jayes, RS, Zimmerman, JE, Wagner, DP, et al., "Do Not Resuscitate Orders in Intensive Care Units," JAMA 270 (1993): 2213-17. Lemeshow, S, Teres, D, Avrunin, JS, et al., "Mortality Probability Models (MPM II) Based on an International Cohort of Intensive Care Patients," JAMA 270 (1993): 2478-86. Loewy, EH, "Changing One’s Mind: When is Odysseus to be Believed?" Journal of General Internal Medicine 3(1988): 54-58. Dirksen, SR; Lewis, SM; and Collier, IC, "Cardiopulmonary Resuscitation," in Clinical Companion to Medical-Surgical Nursing (St. Louis: Mosby, 1996), 622-28. Linder, KH and Wenzel, V, "New Mechanical Methods for Cardiopulmonary Resuscitation (CPR): Literature Study and Analysis of Effectiveness," Anaesthesiology 46 (1997): 220-30.]
