Successful Resuscitation From In-Hospital Cardiac Arrest—What Happens Next?
Authors: Derek C. Angus
Journal: JAMA (2015)

Few moments in medicine are more vividly and regularly captured in the lay media than the resuscitation response (ie, code blue) to an in-hospital cardiac arrest. However, there is concern that outcomes from resuscitation efforts are far better on television than in real life.1 Consequently, the public’s view of the implications of in-hospital cardiac arrest may be distorted, thereby complicating ensuing care planning, especially with regard to prognosis and whether to limit care or institute do-not-resuscitate (DNR) orders. In this issue of JAMA, Fendler and colleagues2 provide a comprehensive and contemporary description of what actually happens to patients who experience in-hospital cardiac arrest, focusing on those for whom resuscitation results in successful restoration of spontaneous circulation (ROSC) and whether subsequent institution of DNR orders in these patients is alignedwith their prognosis. The authors analyzed the Get With the Guidelines Resuscitation registry, a large database of in-hospital cardiac arrests at several hundred US hospitals. The analysis was limited to patients for whom there were no prearrest DNR orders and whose cardiac arrest occurred while the patient was admitted to a hospital ward or intensive care unit. For patients who achieved successful ROSC, the authors used the cardiac arrest survival post-arrest resuscitation in-hospital (CASPRI) prognostic tool to estimate the likelihood of being discharged alive without severe neurological dysfunction and then determined if and when DNR orders were instituted across deciles of risk. Among 59 589 patients with cardiac arrest, 25 618 (43%) diedduringattemptedresuscitation.Of the33 971patientswho had successful ROSC, 26 327 (77.5%)were available for analysis.For thisgroup, theoverall likelihoodofdischargealivewithout severe neurological disability was only 24%. Do-notresuscitate orders were placed within 12 hours for 22.6% of patients, and an additional 14.5% of patients had DNR orders placed up to day 5 after cardiac arrest. In the best prognostic decile (n = 2396), DNRorderswere placed in the first 12 hours for 169 (7.1%)patients, and 1550 (64.7%)weredischargedwith favorable neurologic outcome. In contrast, of the 2667 patients in theworst prognostic decile, 108 (4%) had a favorable outcome, yet only 959patients (36%) hadDNRorders placed. This pattern was similar for DNR orders placed up to 5 days. Not surprisingly, patients in the best prognostic decile were younger, had less preexisting comorbidity, andhad less acute severity of illness, such as a lower chance of requiring mechanical ventilation, than patients in the worst-risk decile. Within the best decile, patients who had DNR orders placed wereolder andhadmoresevere illness than thosewhodidnot. Within theworst prognostic decile, however, the clinical characteristics were quite similar between patients who did and did not have DNR orders placed. It is likely that this study reflects currentUSpractice, even though thehospitals representonly 10%ofallUShospitals and participatevoluntarily. Inaddition,amoderatenumberofcases were excluded from analysis because of missing data, although the authors demonstrated that thebaseline characteristics of these patients were similar to those included in the analysis. Using the CASPRI scorewas a sound approach to assess the extent towhichdecisions to instituteDNRorders varied based on patient characteristics, although it is important to note that this score is not used currently by clinicians. Do-not-resuscitate orders are not analogous towithdrawal or withholding of life support. It is possible that, absent DNRorders, care was nonetheless limited in other ways for patients with poor prognosis. However, hospital costs, length of stay, and resourceuseamongpatientswithpoorprognosisyetwithout DNR orders were high, suggesting anywithholding of life support occurred late in the course of care. These results could be framed as a glass half-full or halfempty. On the one hand, it is reassuring that DNR orders, if placed, are generally done quickly and appear to be instituted infrequently for patients likely to fare well and commonly for those likely to fare poorly. However, two-thirds of patientswith anextremelypoor chanceof good recoverywere managedwithout institutionofDNRorders and incurredhigh costs of care. Given that cardiac arrest occurs in a broad range of patients, and that there are only a fewcasesperhospital per year,most clinical teamswill only occasionally care for a survivor of in-hospital cardiac arrest. It is therefore quite possible that the primary teammay be neither good at nor comfortablewithestimatingprognosis. Inmany instances, cardiac arrest substantially changes prognosis, with potentially important implications for aggressiveness of care. Both the clinical team and family members need to absorb the information. It is perhaps surprising that most DNR orders were instituted so soon after cardiac arrest. As can occur when relying on registry data, the study by Fendler et al has some important missing information, especially on the large portion of patients with very poor prognosis for whom DNR orders were not instituted. What were the opinions of the clinical team and familymembers in these instances? What were the patient’s preferences? What efforts were undertaken to establish a prognosis and ensure converRelated article page 1264 Opinion