Rethinking Emergency Medicine


How You Are Going to Die, Step-by-Step (by the numbers)

When I first learned CPR in my EMT training, we were taught to mark our chest compressions by the steady, 110 beat per minute rhythm of the Bee Gee's disco superhit, Stayin' Alive. Nothing was mentioned about the likelihood that the patient did in fact stay alive, or the dark alternative that working EMTs in the field would teach me: Queen's Another One Bites the Dust. So, the first time I arrived at a cardiac arrest and saw the resigned mechanical motions of the first responders who had begun resuscitation on the elderly man unconscious on the floor, I was taken aback. No urgent orders were barked, no breaths were held.

As I drove to the hospital, the grunts of my partner's compressions and the hollow sound of air being forced from the patient's lungs now masked by the ambulance's sirens, the man's wife calmly sat in the passenger's seat and called her children and her sister and informed them of the situation. Her husband was in his 80s; he had terminal cancer; his list of chronic illnesses was longer than would fit in his chart. Her voice conveyed resignation, maybe even relief.

But thirty minutes later, the resuscitation efforts were still underway in the emergency room although no heartbeat or spontaneous respiration had been established. The emergency room staff had lost the urgency with which they usually treated critical patients, and as arms fatigued, I was tapped to take over the chest compressions. As I interlaced my fingers and began playing that famous disco baseline in my head, I found the man's chest softer than expected, his ribcage collapsed from thousands of two-armed thrusts. Each beat forced blood from his mouth and nose--likely a result of either the tube that had been inserted into his windpipe, or puncture wounds in his lungs from the bones we had broken.

More than an hour after CPR had begun, the supervising doctor finally called it. We had, from a legal standpoint, done everything we could have. As I walked past the open door of the "family room", where his wife and children waited dry-eyed for news, I tried to hide my bloody, gloved hands. I wondered what the undertaker would have to do to prepare the man for his funeral.

Countless lives have been saved by CPR. Regulating medical authorities and medical researchers have repeatedly found it ethical, cost-effective and worthy of the risk. But while it may generally be valuable tool in emergency medicine, I had serious questions about this particular application. Was this something the man himself would have wanted done had he been able to choose? Did the chance that a body that frail would have recovered justify the damage we had done to it? What sort of quality of life would he have had had he miraculously survived?

To state the most obvious of self-evident truths, we all will die. For people who are of advanced age, have chronic and terminal illnesses, this truth is all the more certain and immediate. The blanket use of CPR (with the exception of the rare cases where patients have signed do not resuscitate orders) seems to be a vehement denial of this truth. It is also indicative of a generalized unwillingness in American society to discuss death and how the way our lives end can be improved. In our unwillingness to grapple with our individual mortalities, we ignore what dying will look like as a result.

So here it is: How you are going to die, step-by-step, by the numbers.







You're sick.

Patient 1

Age: 81

Complaint: Rapid heartbeat

Diagnosis: Heart attack

Chronic conditions: Diabetes

Diagnostic tests performed: 0

Medical interventions performed: 0

Medicines administered: 0

Did patient survive? No

I wanted to try to understand whether this experience was representative of the healthcare system more generally, so I did some research. Pulling together data from the National Hospital Ambulatory Medical Care Survey—an annual collection of detailed records of patients who visited hospitals across the US—it quickly became clear that my experience of the emergency medical system in a poor neighborhood of a major city is exceptional in some ways. The connection between poverty and chronic health conditions is well established, and with a 34% poverty rate among people over 65, the neighborhood I work in is likely to have a higher burden of very sick elderly patients.

That being said, at some point you will be sick. Part of acknowledging that we will all die is realizing that we will become sick first. At some point your body will begin to break down and you will find yourself in contact with the medical system. At some point you will probably get sick enough that your heart will fail, and unless you have given specific instructions for how you want your life to end, you will be whisked off to an emergency room where the full machinery of the emergency medical system will be engaged to keep you alive. So what happens next?






They break your ribs

In the movies, CPR functions like a set of jumper cables on a dead battery. A few quick thrusts and a breath of air and patients open their eyes and gasp for new breath. In reality, CPR is a brutal process. Chest compressions, particularly on older bodies, end up breaking the ribcage in order to press hard enough on the heart to artificially circulate blood. Broken ribs and sternums can cause internal bleeding and puncture organs. Even when successful in restarting spontaneous breathing and circulation, the underlying cause for the heart failure still likely remains.






You probably die.

The other misleading impression the media gives is that CPR usually works. Ones study found that 75% of patients on US TV shows who underwent CPR recovered. In reality, the number is more like 18%. Outside of a hospital setting it drops further (1-3% by some estimates ), and for older patients—those for whom it poses the highest risk of complications; who are most likely to have a terminal illness; and who are likely to have the least quality of life afterward—the rates are almost vanishingly low.






If you don't, you may be brain-dead

In the time between when your heart stops and CPR begins, your brain is not receiving oxygen. Poor CPR may extend the time when your brain is under-oxygenated, and the resulting cell death can lead to physical and mental disability even when CPR succeeds in resuscitating you. These risks are not taken into account when deciding whether to initiate CPR. The first priority is restoring circulation and breathing — considerations about other organs take the back seat.






The whole process is costly

Estimates are hard to come by, but a 2001 study estimated CPR to cost $5,900 in today's dollars. However, when patients do survive, their average medical bill is in the hundreds of thousands. CPR also requires a significant amount of time from a variety of emergency medical personnel. And it can be deeply traumatizing for family members. As I mentioned before, medical researchers and regulatory boards have repeatedly found it both cost-effective and ethical, but these assessments are blanket policies that cannot account for all of the factors in specific cases—particularly among patients with terminal illness—that can alter this calculus. The incidence of patients receiving CPR has also climbed in recent years, exacerbating the problem.






Meanwhile...

The chronic diseases that put you there are not being prevented.

98% of all hospital readmissions among Medicare beneficiaries in 2010 were for patients with chronic illnesses. Chronically ill patients cycle through the medical system, being treated for the symptoms of diseases for which we have no cures. Elderly patients have a 23% rate of obesity, a 29% rate of hypertension, and a 52% rate of high cholesterol. In 2008, this resulted in $234 billion in spending on cardiac care, while only $68 billion was spent on prevention. While improvements in care have improved in recent years, extending the lifespans of millions, this focus does not have as clear a benefit in terms of quality of life.






And almost no one is talking about how we can improve dying.

This may all read like some geriatricidal argument for denying CPR to the elderly. It's not. But, the problem that is causing our healthcare system to invest in emergency medical care that is traumatic to the patient with little chance of a positive outcome is our unwillingness to grapple with how we want to die. While most people would probably agree that the type of death I have described is not how they imagined the end of their life, very few have taken practical steps to take control of the situation. Only half of Americans have talked to their doctors about end-of-life care and only a quarter have an advance directive laying out the type of care they would like to receive. Legal obligations and the threat of malpractice suit force medical providers to always err on the side of resuscitation. As a result, the illness or illnesses that we are bound to encounter will send us all back to the ER table to be pulled back from the brink of death as many times as the medical system can bring us back from the brink until our bodies final give.






...but some people are.

Check out Let's Have Dinner and Talk about Death and The Conversation Project. Or shoot me an email. Dying well starts with talking about death.