Teach the Controversy
I want to be absolutely clear before I continue this post. I believe in out-of-hospital CPR efforts being started by bystanders. What you are about to read, however, is an exploration of objections that were released in response to the 2017 American Heart Associations “Call To Action” that aimed to greatly increase the number of bystanders performing CPR.
Civic Engagement surrounding bystander intervention is as much philosophy as it is psychology, sociology, and science, so I want to start by challenging my own assumption that immediate bystander CPR is ethically a universal good.
You may be shocked to learn that CPR has been described as a “fetish” or a “golden calf.” 12 Reading abstracts such as the one from Dr. Rosoff’s and Dr. Schneiderman’s 2017 American Journal Of Bioethics article titled Irrational Exuberance: Cardiopulmonary Resuscitation As Fetish below can easily put a pit in the stomach of any resuscitation advocate.
The Institute of Medicine and the American Heart Association have issued a "call to action" to expand the performance of cardiopulmonary resuscitation (CPR) in response to out-of-hospital cardiac arrest. Widespread advertising campaigns have been created to encourage more members of the lay public to undergo training in the technique of closed-chest compression-only CPR, based upon extolling the virtues of rapid initiation of resuscitation, untempered by information about the often distressing outcomes, and hailing the "improved" results when nonprofessional bystanders are involved. We describe this misrepresentation of CPR as a highly effective treatment as the fetishization of this valuable, but often inappropriately used, therapy. We propose that the medical profession has an ethical duty to inform the public through education campaigns about the procedure's limitations in the out-of-hospital setting and the narrow clinical indications for which it has been demonstrated to have a reasonable probability of producing favorable outcomes3
This same edition of the journal was peppered with arguments against the broad application of CPR on a non-consenting public. Fingers are pointed at the media for inaccurate portrayals of CPR. In Dr. Joseph Kotva and Dr. Mark Fox’s article CPR as a Golden Calf, CPR is looked at as a performance akin to religion, which the authors argue medicine has supplanted in some respects. They suggest it has unwarranted reverence.
CPR reminds us that medicine does battle with death. Indeed, given the usual depiction, CPR arguably reenacts (makes repeatedly present) a kind of resurrection. As with any fetish, we must repeatedly return to CPR to experience its power. CPR makes tangible, bodily enacts, the religious narrative of medicine’s battle with and control of death.4
The series expands further on the authors’ central point that CPR has an oversized role in the public mind despite evidence of its generally applied effectiveness. It’s reiterated in this and the Rosoff/Schneiderman article that there is a “lack of any strong data showing that such efforts are rewarded by increased percentages of patients either surviving to hospital discharge or, more importantly, surviving with acceptable neurologic damage.”5 In other words, they are suggesting CPR zealots may be false prophets.
Dr. Arthur R. Derse takes a slightly different view. Instead of viewing it as a fetish, he perceives it as a bias towards “erring on the side of life” even when faced with a likely poor outcome.6 If you are picking up on a theme, you’re not alone. All the authors seem to be addressing a key point that I do believe many advocates will agree with: not every patient is a candidate for being considered a “full code” regardless of that patient’s wishes.
Sprinkling Some Facts
Let’s put some modern statistics to their 2017 article. It’s important to note that these top-box scores do not completely reflect those discharged with good neurological outcome.
During the pandemic, one study suggested overall survival from sudden cardiac arrest fell from 15% to 10%.7 The 2021 Cardiac Arrest Registry to Enhance Survival (CARES) Annual Report found just a 9.1% overall survival rate for non-traumatic cardiac arrests.8
According to the CARES report, When a bystander witnessed a cardiac arrest, survivability jumped to 13.5% that same year. Unwitnessed arrest survival rate dropped to 4.3%.
In the most survivable cases, that is meeting the Utstein criteria of being in a shockable heart rhythm upon discovery OR an Utstein Bystander criteria of being shockable upon discovery + care initiated by a bystander, these rates increase to 29% and 32.5% respectively.
Most advocates know, bystander interventions do make some difference. The well documented “slope of death” illustrates this, and was put into an excellent GIF form by Tom Bouthillet at the link below.
It is unfortunately true, and in line with the point most of the prior cited articles were making, that with a substantial amount of unwitnessed arrests at home, our past efforts performing CPR often do not produce the positive outcomes. However, the data does show that immediate CPR and defibrillation are necessary interventions under the right conditions. If withheld or delayed, survivability drops significantly.
Agreeing to both Agree and Disagree
If we want to encourage a society that renders aid when it is needed, we necessarily must confront this critical concept of consent. Attendees of the Resuscitation Academy and various outreach events have heard the mantra that “Everyone In VF Survives.”9 Everyone who has responded to multiple resuscitation efforts, however, knows that this isn't necessarily the case, nor is every patient in a shockable rhythm or receiving critical interventions upon arrival.
If defibrillation is the indicated treatment for a patient and has statistically significant odds of improving the patient’s condition, then it would seem unethical to withhold it from a patient. Since immediate CPR is a critical part in preventing final death and arguably necessary for favorable neurological outcome in patients until a cause is found, it follows that a patient with a reversible cause should have it administered to them as soon as possible.
The authors and I are in agreement, however, in pointing out that for some patients, no treatable cause will be found. Those with terminal illness or significant comorbidities may benefit from serious conversations with their doctors about the formation of Physicians Orders for Life Sustaining Treatments, where realistic expectations and facts can be addressed in order to provide a measure of “consent” to the process. Resuscitators may benefit from being trained to closely follow these guidelines, which may require more legislation and public education in certain places. However, the suddenness and limited information available found with many out of hospital codes makes this impractical.
Further, I agree with the authors that CPR is inaccurately portrayed in the media, and while I disagree with their fetishization conclusions, poorly performed CPR or non-indicated shocks contribute to the unrealistic expectations of CPR effectiveness. This could create an expectation vs. reality trap that hampers efforts to increase bystander interventions (more later).
Why Explore These Objections
I started this project with the goal of organizing thoughts related to increasing bystander willingness to perform CPR. By considering the ethical arguments against a seemingly benevolent act, I wanted to start from a place where CPR performance isn’t an a priori obvious.
Yes, we need to be clear-eyed in our measurements and engage full-hearted in our efforts to improve in order to win over resuscitation skeptics. They are correct, wide regional variations, socioeconomic/racial divides, resuscitation practices, and in overall outcomes reflect poorly on the virtue of CPR. Improvement requires effort, but absent bystander efforts there is no improving resuscitation. CPR has its benefits, and while the authors argue against overselling the practice or wish it was more consensual, it would be unethical to remove it from practice completely as it does demonstratively save lives.
In order to, as the lone dissenting article in the journal series stated, promote CPR as a “Civic Duty,” we must accurately portray what we mean by increasing bystander CPR efforts.10 That is not to say every single patient is treated the exact same way without regards to their own uniqueness, but that every patient is equally entitled to their own best chance of neurologically in-tact survival. To accomplish this, the public must be a part of the equation. As the team of dissenters, led by Dr. Torben K. Becker, stated in their response to Dr. Rosoff and Dr. Schneiderman,
(B)ystander CPR is the most effective single intervention to improve survival from cardiac arrest with good neurological recovery. Thus, we must educate all members of our society. Every life counts, making bystander CPR a “civic duty.”11
Rosoff PM, Schneiderman LJ. Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish. Am J Bioeth. 2017 Feb;17(2):26-34. doi: 10.1080/15265161.2016.1265163. PMID: 28112611. https://pubmed.ncbi.nlm.nih.gov/28112611/ ↩
Kotva JJ, Fox MD. CPR as Golden Calf. Am J Bioeth. 2017 Feb;17(2):45-46. doi: 10.1080/15265161.2016.1265175. PMID: 28112626. https://pubmed.ncbi.nlm.nih.gov/28112626/ ↩
Rosoff PM, Schneiderman LJ, https://pubmed.ncbi.nlm.nih.gov/28112611/ ↩
Kotva JJ, Fox MD, https://pubmed.ncbi.nlm.nih.gov/28112626/ ↩
Rosoff PM, Schneiderman LJ, https://pubmed.ncbi.nlm.nih.gov/28112611/ ↩
Derse AR. "Erring on the Side of Life" Is Sometimes an Error: Physicians Have the Primary Responsibility to Correct This. Am J Bioeth. 2017 Feb;17(2):39-41. doi: 10.1080/15265161.2016.1265168. PMID: 28112610. https://pubmed.ncbi.nlm.nih.gov/28112610/ ↩
Chugh HS, Sargsyan A, Nakamura K, Uy-Evanado A, Dizon B, Norby FL, Young C, Hadduck K, Jui J, Shepherd D, Salvucci A, Chugh SS, Reinier K. Sudden cardiac arrest during the COVID-19 pandemic: A two-year prospective evaluation in a North American community. Heart Rhythm. 2023 Mar 23:S1547-5271(23)00327-2. doi: 10.1016/j.hrthm.2023.03.025. Epub ahead of print. PMID: 36965652; PMCID: PMC10035806. https://www.heartrhythmjournal.com/article/S1547-5271(23)00327-2/fulltext ↩
2021 CARES Annual Report, https://mycares.net/sitepages/uploads/2022/2021_flipbook/index.html?page=36 ↩
Ten Steps for Improving Survival from Sudden Cardiac Arrest, https://globalresuscitationalliance.org/downloads/ebook/10_steps_2019.pdf ↩
Becker TK, Bernhard M, Böttiger BW, Rittenberger JC, Epitropoulos MG, Becker SL. Bystander Cardiopulmonary Resuscitation: A Civic Duty. Am J Bioeth. 2017 Feb;17(2):51-53. doi: 10.1080/15265161.2016.1265173. PMID: 28112624. https://pubmed.ncbi.nlm.nih.gov/28112624/ ↩
Ibid, emphasis mine. ↩