Clinical Geriatrics

Cardiopulmonary resuscitation (CPR) was developed to treat individuals who have a sudden unexpected cardiac arrest due to a heart attack, drug overdose, hypothermia, drowning accident, or other reversible condition. However, CPR is now widely used to treat arrests in people with severe underlying illnesses and poor overall likelihood of survival. The purpose of this article is to discuss patient and physician attitudes regarding CPR and survival from CPR, and to examine published general and disease-specific survival rates from in-hospital CPR. Through this, we aim to aid physicians in having useful conversations with patients and their families about survival rates from in-hospital CPR.

There are many misconceptions surrounding survivability from CPR, among both physicians and patients. The general public grossly overestimates the effectiveness of CPR, and attitudes about CPR are often shaped by media portrayal. A study reviewing 97 episodes of the television shows “ER,” “Chicago Hope,” and “Rescue 911” in which CPR was depicted revealed that 75% of persons survived the immediate arrest and that 67% survived to hospital discharge.1 In another study of patients age 70 years and older, 81% believed that their chance of surviving inpatient CPR and leaving the hospital was 50% or better, and 23% believed that their chance was 90% or better.2

Conversely, studies have shown much lower CPR survival rates. A meta-analysis of studies examining the rates of survival from in-hospital CPR found an overall immediate survival rate of 40.7% and a survival to hospital discharge rate of 13.4%.3 More recently, a Canadian study of 247 hospitalized patients who underwent cardiac arrest found that only 22.4% of those with witnessed arrests survived to hospital discharge, and that only 1% of those with unwitnessed arrests survived CPR to hospital discharge.4

Physicians also are poor at predicting survival from CPR. In a 1996 study, 51 attending physicians and residents in internal medicine and family practice were given one-page summaries of admission data for patients who underwent in-hospital CPR. The physicians were then asked to predict survival to stabilization and survival to discharge. The results showed that physicians were no better at identifying patients who would survive resuscitation than would be expected by chance alone.5 In addition, there appears to be little consensus among physicians on the definition of futile treatment as it pertains to CPR survivability. Curtis et al6 conducted a study of second- and third-year residents who applied the futility rationale and found that the definition of futility varied widely among resident physicians.

When examining survival from CPR, it is crucial to assess not only the immediate success of a CPR attempt, but also survival of the patient to hospital discharge. Simply surviving a CPR attempt does not necessarily translate into the patient surviving until discharge. This point was emphasized in a 1988 retrospective review by Taffet and colleagues,7 which showed that survival to discharge is a meaningful marker for CPR survivability, particularly in elderly patients. Authors found that of the 77 CPR efforts in patients age 70 years or older who had arrests, 31% were successful, and 92% of these initial survivors were alive after 24 hours. However, none of these patients survived to hospital discharge.7 In addition, CPR can be a particularly stressful event to endure, with patients possibly sustaining rib fractures and undergoing intubation and mechanical ventilation. For the families of patients who do not survive, they are subjected to watching their loved ones go through what some may consider an “undignified” and an uncomfortable, rather than a “natural,” death.

Factors That Influence CPR Survivability

Several studies have looked at survival from in-hospital CPR, and results vary depending on patient type, underlying conditions, and setting.