In Anticipation of the Inevitable: Preparing Older Americans for Cardiac Arrest

Conquering death has become the unspoken battle cry of the storied successes of contemporary clinical medicine. There is an important distinction to be made, however, between premature unexpected death and universal and ordinary death at the end of life. Unexpected and premature out-of-hospital cardiac arrest (OHCA) remains a significant public health challenge worldwide. When circulation stops, time is of the essence. In 2010, the American Heart Association set an ambitious goal of doubling both bystander cardiopulmonary resuscitation (CPR) and survival to hospital discharge for OHCA by 2020; and major public campaigns emphasize treating all OHCAs, with few exceptions. No one would disagree with the importance of striving to improve meaningful neurological survival from unexpected OHCA, yet OHCA and ordinary death travel together. Although by no means applicable to all, older adults greater than 80 years of age are more likely to be frail and have chronic health conditions, such as heart and lung disease, compared with younger adults. These comorbidities, which place them at risk for sudden cardiac arrest, also increase the probability of having a poor outcome (ie, permanent neurologic damage, fractured ribs, and lacerated organs) after OHCA. In this issue of Journal of the American Geriatrics Society, Druwé and colleagues explore clinicians’ perceived circumstances, appropriateness, and outcomes of the last recalled resuscitation attempt in someone aged 80 years or older with OHCA. The study asked health clinicians to remember their last resuscitation and to recall information such as type of rhythm, witnessed status, and outcome. In spite of greater than 50% of those surveyed believing that the CPR was appropriate, the survival to discharge rate was universally poor for the majority of OHCA patients: 0% for unwitnessed, nonshockable rhythms and 1.3% for unwitnessed, shockable rhythms. Only 10% of all OHCA patients in this cohort had an shockable initial rhythm. Clinician-perceived appropriateness for resuscitation for OHCA with witnessed, shockable rhythms was 71% and survival to discharge was significantly better for this cohort at 10%. Finally, CPR was commonly initiated for OHCA occurring in nursing homes, and survival to hospital discharge for these patients was also 0%. The method of assessment in this study is clearly subject to several types of bias, including recall and response bias. There was also missing information, such as 17.5% missing for witnessed status and type of rhythm and 12% missing for outcome of the resuscitation efforts. However, more systematic data collection studies of CPR outcomes has also found that older adults have poor survival to discharge after OHCA. Interestingly, age is a weaker predictor than initial cardiac rhythm, witnessed arrest, and bystander treatment in determining outcomes from resuscitation efforts. Importantly, success from resuscitation should also include outcomes beyond discharge, such as preservation of meaningful cognitive and functional status. For this, several studies also confirm a poor shortand long-term neurological recovery in older adults. The current article, in context of other evidence, highlights the conflicting emotions that accompany the urgent sense of duty for emergency responders involved in resuscitation efforts for older adults. Potential for harm in this setting is clearly present for both the subject of resuscitation efforts as well as those called upon to perform the resuscitation. The time-sensitive nature of OHCA makes it extremely difficult to create a solution that can be nuanced and patient oriented in the field. Treatment for cardiac arrest often begins before emergency medical professionals arrive as 911 dispatchers are trained to advise CPR if OHCA is suspected. Three principles to prevent harm from OHCA resuscitation in older adults should be considered. The first is better physician-patient communication about death and CPR. It is not clear how often physicians discuss dying and outcomes of resuscitation outside of the hospital, but without coordination for that type of discussion, it may be inconsistent or left to chance. Prior data from a large community cohort suggests that most older adults, when properly informed of likely benefit of successful resuscitation efforts, would choose less aggressive care in general as they become sicker and more frail. The second consideration is increased use of out-ofhospital do-not-resuscitate orders. In most states, outpatient primary providers have the option to issue a nonhospital donot-resuscitate (NH-DNR) order that can be communicated with emergency professionals in the event of OHCA. A survey of primary providers in New York State (legislation for NH-DNR enacted in 1993) found that up to 30% of physicians surveyed had never issued an NH-DNR, despite caring DOI: 10.1111/jgs.16269