Cardiopulmonary Resuscitation in Coronavirus Disease 2019: Rebalancing Risk, Reward, and Autonomy.

Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. To say coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has changed the relationship between the general public and critical care medicine grossly understates the effects clinicians have seen in their daily lives. The professionals who work in ICUs globally saw news articles and commentaries about ventilator availability, allocation of scarce resources, and prone positioning in acute respiratory distress syndrome. Out of necessity, ICUs restricted families and visitors, but the world got to peek inside through the news. In March 2020, when cases were rising sharply in New York City and Northern New Jersey, news outlets published that hospitals considered implementing universal do not attempt resuscitation (DNAR) orders for COVID-19 patients (1, 2). Critical care clinicians know that DNAR orders only become active in the setting of a cardiac arrest. However, to the general public, the difference between full code and do not resuscitate often means, “will you fight to save my life or not? ” In the United States, admitting clinical teams ask the patient or their substituted decision-maker about resuscitation wishes. In the absence of a patient declining full cardiopulmonary resuscitation (CPR) measures or an advanced directive/physician order of life-sustaining treatment, the default is “full-code,” indicating the patient accepts CPR and intubation with mechanical ventilation in the event of an inhospital cardiac arrest (IHCA). The purpose of resuscitation in both out-of-hospital cardiac arrest (OHCA) and IHCA is to prolong life, allow time to reverse the disease processes causing the physiologic decline, and provide a neurologically acceptable outcome. However, the gulf between expected results and reality is vast. The public grossly overestimates the success of CPR. In 2000, 1,831 participants in community settings in the United States estimated CPR’s overall survival rate to be 54% (3). With the given specific clinical scenarios, they estimated CPR survival to be 79% if a 75-year old otherwise healthy patient experienced a cardiac arrest (3). A more recent survey of 1,000 participants (noncritically ill patients and their families) evaluated both an OHCA and an IHCA scenario (4). In a 54-year old who had suffered a heart attack at home and required CPR, respondents estimated a 72% chance of survival and predicted a 65% chance of neurologic recovery. For a postoperative 80-year-old patient, survey participants indicated a 57% chance of survival and a 53% chance of full neurologic recovery (4). Observational data of OHCA and IHCA survivorship contrast against these optimistic predictions. In the United States, 2016 estimates of adult OHCA and IHCA survivals with functional neurologic outcomes were 9% and 15%, respectively (5). A disconnect between perception and clinical experience can create conflict between families and treating clinical teams when discussing limitations on resuscitative care. Tension rises when the perceived Salina M. Wydo, MD1