by Carolyn Thomas ♥ @HeartSisters
Before my heart attack, much of what I knew about CPR (cardiopulmonary resuscitation) was learned by watching TV medical dramas like Grey’s Anatomy. Researchers who study how television has impacted public opinion suggest that TV actors following their cardiac arrest scripts are heroically brought back to life by another TV actor pretending to perform CPR over 70 per cent of the time. (1) Pulse restored, smiles of relief all around, and the cheerful patient and family heading for home while waving in gratitude to the brilliant hospital life-savers.
For real-life heart patients, however, we know that most people whose hearts suddenly stop don’t survive. Only about one-quarter make it out of the hospital alive. Of those survivors, the American Heart Association reports that nearly one-third are seriously disabled.(2)
Cardiac arrest is NOT the same as a heart attack (although people like me who have survived a heart attack are at higher risk of cardiac arrest both during and after that heart attack than those without a cardiac history). My heart attack was like a plumbing problem (essentially, a blocked pipe preventing blood flow to the heart muscle) – but sudden cardiac arrest is an electrical problem (the heart’s electrical circuits can’t maintain a heartbeat). So during cardiac arrest, blood can’t flow to the organs of the body, including the brain, which is why so many people don’t recover after cardiac arrest.
In a 2021 study published in the American Journal of Emergency Medicine, researchers assessed what home viewers would learn about CPR as demonstrated by TV actors.(3) The researchers described what they’d learned after studying hundreds of episodes of medical dramas as “a missed opportunity for improving both performance and communication on CPR.”
In other words, not only were the CPR techniques used by TV actors during their cardiac arrest scenes significantly more likely to be demonstrated incorrectly, but the post-CPR outcomes were also portrayed inaccurately.
Not surprisingly, when actor/doctors on the screen push down on the chests of actor/patients, for example, the compression strength is not nearly as forceful as real-life rib-cracking CPR needs to be to actually maintain life.
This study also found that patients (and their family members) who believe those inappropriately optimistic CPR prognoses (“70 per cent survival”) portrayed by television actors are more likely to expect aggressive medical care when facing their own medical crises, as researchers explained:(3)
“The public has unrealistic views regarding the success of CPR, and one potential source of misinformation is medical dramas.
“Prior research has shown that depictions of resuscitation on television are skewed towards younger patients with acute injuries, while most cardiac arrests occur in older patients as a result of medical co-morbidities. Additionally, the success rate of televised resuscitation on older shows has vastly exceeded good outcomes in the real world.
“Medical dramas continue to focus on trauma as the main cause of cardiac arrest and portray favorable outcomes more frequently than should be expected.
“Healthcare workers should anticipate the need to counter misinformation when discussing patient goals of care and end-of-life planning.”
In a compelling interview in Shots: Health News From NPR, we learn more about “the widespread misconception of what CPR can and cannot do. CPR can sometimes save lives, but it also has a dark side.”
Some of you reading this might in fact have been one of those patients whose stopped hearts have been resuscitated by CPR. And if you’re able to read this, you’re one of the small minority who didn’t die or suffer permanent neurological, cognitive or psychological damage after the CPR that successfully restarted your pulse. You probably never saw any “dark side” to CPR.
Sadly, as researchers noted here and elsewhere continue to remind us, many are not so lucky.
Yet these researchers still ask the important question: while it’s possible to endure a ‘successful’ resuscitation that restarts the heart and thus saves a life – what kind of life will that be? Factors like the patient’s age (younger is better) or how long the patient’s heart was stopped before CPR began (sooner is better) or general physical condition (healthy is better) or where the CPR took place (in-hospital is better than out-of-hospital ‘bystander CPR’) or who was performing the CPR (skill and experience are better) – all of these things help to determine a fairly accurate post-CPR prognosis, according to what’s called the Cerebral Performance Scale – or CPC.(2)
This scale ranks five categories of neurological deficit that can result from sudden cardiac arrest, all the way from Category 1 (“full consciousness/return to normal life”) to Category 3’s serious brain injury (“limited cognition/significant neurological deficits”) or Category 5 (“brain death, never regains consciousness”).
The general public tends to incorrectly believe (from television, movies or high-profile professional athletes who are famously resuscitated during cardiac arrest) that the CPR drama they’ve watched on TV is always a miracle cure for a stopped heart. This could be true for some – but sadly, only for a small minority and only under ideal circumstances.
But The New England Journal of Medicine published an interesting CPR study suggesting that people over age 60 actually tend to change their minds about wanting heroic CPR measures for sudden cardiac arrest once they learn the actual survival statistics – along with the commonly experienced neurological harms that can follow. For both acute and chronic illness cases, research participants were significantly more likely to change their minds once they were informed about the reality of post-CPR survival(5):
“When asked if they wanted CPR in case of sudden cardiac arrest, 41 per cent of participants opted for CPR before learning the probability of survival to discharge (10-17 per cent). After learning the probability of survival, only 22 per cent opted for CPR.
“And among older adults, only 6 percent of patients who were 86 years of age or older opted for CPR under these conditions.”
Language matters too, as the NPR interview reported from physician and bioethicist Dr. Holland Kaplan, who explained:
“Doctors may ask family members if patients ‘want everything done’ if their heart stops. But that puts a burden on both patients and families. Who wants to feel like they don’t want everything done for their loved one?’
Instead, if CPR seems futile or hurtful, she suggests recommending the option to “allow natural death” instead of “do not resuscitate.”
Dr. Kaplan also told NPR that, even for healthcare professionals who perform CPR during cardiac arrest, “the bad experiences far outnumber the good ones, unfortunately. It’s no wonder that many doctors choose NOT to receive CPR themselves.”
Dr. Ken Murray explained why in this classic essay in TIME magazine called Why Dying is Easier for Doctors.
My own personal experience is also why I now have a DNR (Do Not Resuscitate) order on my own Advance Care Planning documents. These have been shared, discussed, regularly updated carefully and signed by my closest family and my GP. My decisions stem from 10 years of regularly visiting my once-bright, vivacious, brilliant friend in the longterm care institution she’d been sent to after being “successfully” resuscitated. Those years had a profound and life-altering effect on me. At first, those of us who knew and loved her were so relieved that she was still alive, that she hadn’t died. But for over a decade, she deteriorated alarmingly, lying helpless in bed, in a dimly lit 5-bed ward, day after day, year after year. She often wept in my arms during my visits, repeatedly sobbing: “Every day, I wish they had not found me in time.” After these visits, I sat in the parking lot and wept, too.
Signing a DNR order – or conversely deciding that you DO want to be resuscitated – is an intensely personal decision that should be clearly communicated – both verbally and in writing – to your family and to your doctors. What I or anybody else decides has nothing to do with the decisions of others.
For more about informing your family and doctors about what YOU want in case of cardiac arrest, read: “Who Will Speak For You When You Can’t?” Not having your important people on the same page can mean a terribly stressful tug-of-war some day in some Emergency Department or Intensive Care Unit – between those who may be reluctant to prolong your suffering and others who insist that everything that can be done MUST be done. Please tell them today what YOU want.
And for a more accurate portrayal of what CPR looks like in daily life, skip those Grey’s Anatomy reruns. Instead, watch non-sugar-coated hospital documentaries, like the excellent series Emergency NYC or Lenox Hill (both streaming on Netflix).
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1. Portanova J et al. “It Isn’t Like This on TV: Revisiting CPR Survival Rates Depicted on Popular TV Shows.” Resuscitation. 2015 Nov; 96:148-50.
2. Marinšek M et al. Neurological outcome in patients after successful resuscitation in out-of-hospital settings. ” Bosn J Basic Med Sci. 2020 Aug 3;20(3):389-395.
3. Ramirez L et al. “Cardiopulmonary Resuscitation in Television Medical Dramas: Results of the TVMD2 study.” Am J Emerg Med. 2021 May; 43:238-242.
4. Bitter CC et al. “Depiction of Resuscitation on Medical Dramas: Proposed Effect on Patient Expectations.” Cureus. 2021 Apr 11;13 (4):e14419.
5. Murphy DJ et al. “The Influence of the Probability of Survival on Patients’ Preferences Regarding Cardiopulmonary Resuscitation. N Engl J Med. 1994 Feb 24;330(8):545-9.
♥
Image: PhotoFunia
Q: Have you had an experience of CPR – either as a patient, or as the person doing or witnessing CPR?
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NOTE FROM CAROLYN: I wrote more about making important cardiac decisions in my book “A Woman’s Guide to Living with Heart Disease“. You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Heart Sisters 
Informative and engaging content! I appreciate the well-researched articles and practical tips you offer. Keep up the great work!
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Thank you Raihansabi. . .
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Hi Carolyn,
I have my orders with my doctor and it is just like I did for my mom. I will allow for CPR but only for a limited time and not to the point of cracking my ribs. I allowed that for my mom and they got her heartbeat back in less then 5 minutes, but she was placed on a respirator. She could hear and responded to me. I was there when she coded. I sat there day and night going home only to shower and change clothes. The maximum a person can stay on a respirator without damaging their airways is 14 days, after that it isn’t reversible.
Four days on it and she was doing a little breathing on her own, at the end of week one she was breathing on her own and taken off the respirator. She would answer me and I knew she was still with me. We made a pact that we would give the other a chance, she kept her end of the bargain and I kept mine.
And I would not do that again, she put up a fight. She lived about a week after that and we both knew there was nothing more that could be done but keep her comfortable. The night she passed she pushed me away, she had held onto me every night. I asked her if she wanted me to go home and she said yes, we stayed a few hours longer and when my sister got ready to leave, she pushed me away again. I asked if she wanted me to go home and she nodded. She didn’t want me to see her go as I watched my husband.
I get the call a little after 2 am to let me know she had passed. She was on comfort care and they were getting her ready to come home on Hospice care. I’m glad I agreed to it and allowed her to go in her own time and that I didn’t have to pull the plug. My mom passed at the young age of 94, December 28, 2022 and it’s still very fresh.
Those are the orders I gave my cardiologist and he said he would do it. He had the final say as to what is done. I ask that I only be given a chance to live, but not to drag anything on. He said he would take that responsibility because he watched me come back as I had been down for the count three times when I had my AMI and he called me a fighter. And said he would make sure my wishes were followed.
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Hello Robin – I’m so sorry for the loss of your mother. Thank you for sharing her story. If your mom was “the young age of 94” – or 50 years younger – her death still means losing the only mother you had.
After my own mother died, I read a lovely book called “My Mother’s Daughter” by Rona Maynard, in which she wrote this about when mothers die:
“Baby showers herald the transition to motherhood. Roses, greeting cards and invitations to lunch celebrate Mothers Day every May. Yet, despite out culture’s motherhood mystique, no rituals mark the psychological journey we daughters begin when our mothers die.”
When I worked in hospice/palliative care, we would often observe patients who seemed to wait until their family members were finally out of the room so they could take their last breath alone. This was so common in fact that most hospice doctors commented that patients seem to “choose” their moment of death, almost as if they were hoping their children wouldn’t have to witness that final breath. Very very distressing for the family, who often feel guilty because they’d left the room (yet sometimes this would be the first time the family had finally taken a single break after days around the bedside).
Every grieving experience is so different, whether you’re present for the death or far away. That’s still your mother who is gone. You can be at peace that you were there with her day and night for so many days – until she was ready to see you leave.
Great news about your cardiologist being totally onboard with your wishes. You should also make sure you put your wishes in writing in an Advance Directive – because other doctors (not your cardiologist) may be with you then who won’t know what you and your cardiologist have agreed upon.
Take care. . . ♥
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Hi Carolyn,
My cardiologist has already put those orders in place and they become active anytime I’m admitted to the hospital. It surprised me because I was admitted for observation and the nurse asked if I had advanced directives and when she tapped on it, the file opened. She said it is active anytime I enter the hospital for any kind of procedures. It’s already in my medical records at the hospital. I have a critical care cardiac patient classification so it is in a file that is at the hospital for just that reason. My cardiologist was thinking ahead and they don’t always call him.
Take care,
Robin
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Sounds like it’s all very well organized! 🙂
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Robin, it sounds like you and your mother had a beautiful relationship concerning her end of life events.
On my mother’s last admission to the hospital she declared herself a DNR. A day later she lost consciousness and was actively dying because of respiratory failure. I flew into Chicago from Denver at midnight and just sat there holding her hand telling her she was loved and it was okay to leave.
At some point, I realized the oxymoron of holding her hand and yet telling her it was okay to leave. So I let go of her hand, stopped talking to her and just sat in a chair by her bed. She gently left the earth about an hour later.
When the soul leaves the physical body it is indeed a choice but at a much higher level than our earthly minds comprehend.
My mom was 86 when she died. If she was alive, tomorrow would have been her hundredth birthday.
Thanks Carolyn and Robin for the reminders of the mysteries of the circle of life. We all grasp to control life through CPR, DNRs, doctors, hospitals, medications and lifestyles but ultimately peace comes when we recognize there is a force much larger than ourselves at work.
Blessings
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Beautifully said, Jill. ♥
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Oh my goodness – as a retired hospital nurse and an ICU nurse, I can’t even remember how many times I have done CPR, including on my own mother-in-law!
99% of the time it was in the hospital with FAST access to all the medical professionals, drugs and equipment that are needed to increase the outcome of a good survival. And yet, my own father at the age of 42, and in a hospital environment, ended up brain dead after CPR for a sudden cardiac arrest. That was the 1960s and the techniques and medicines in hospitals have changed a lot since then.
So I have seen every side of the CPR equation, good and bad. Which you’d think would make it a slam dunk to choose DNR every time they ask before a cardiac Cath or an outpatient surgery.
Knowing what I know, I still consider deeply each situation I am in, and whether it is time to declare myself a DNR. Death in a hospital is rarely natural, because we usually only end up in a hospital looking to save or prolong our lives. We show up because we would like everything done and are not ready to die.
Quite a conundrum!
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Hi Jill – unlike most of us, you HAVE seen every side of this conundrum. I appreciate your wise reminder that these situations deserve deep consideration at all times – and each decision is such a personal one. Your Dad was far too young at 42 to die.
I worked in a hospital-based hospice/palliative care unit for years before my unplanned early (heart attack) retirement. Sometimes, even those who have registered for end-of-life care (comfort care only, no further aggressive curative treatment – as we used to say, “neither hastening death nor prolonging life”) – have family members who don’t believe their relative really meant what they said when their DNR order was signed. We used to call these the “parachute relatives” – often the son or daughter from far away who descends on the bedside at the last minute, and then starts telling the medical staff what they should be doing to “save” the parent. This reflects the reality of our death-denying society, and also their firm belief that life MUST be prolonged at all costs (even sometimes despite great cost to the patient).
It’s also why it’s so important to have an open discussion with relevant family members long before the ‘CPR or no CPR?’ decision comes up. I had that discussion with my two adult children around the dinner table after a discussion with my family doctor about my Advance Directive wishes. No surprises to either of them – for years, they’d known the story of my friend who was kept alive for a full decade of misery, and they also knew my own personal post-heart attack perspective that there are worse things in life than dying.
Without this kind of open communication, the fraught situation can lead to that awful scenario where doctors who don’t even know the patient must act as both family mediators and patient advocates at the worst possible time imaginable.
Sometimes, people show up in the hospital not because they seek aggressive care, but because their family members bring them to the hospital to be “saved”.
Take care, Jill – I appreciate your nursing and personal perspectives so much. ♥
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I hear you. In the ICU we often had long range relatives show up out of the blue and demand that “everything be done” at the end of life, often to make up for their lack of attention during the rest of their relative’s life.
Knowing as much as I do can be a burden as well as a gift. If my heart goes into a fatal arrhythmia and stops during my colonoscopy and can be shocked back to life in a few minutes… yes I want it done.
Do I want hours of extraordinary interventions? No. Since I can’t give orders from my unconscious or “twilight” consciousness when to stop. You are right – my relatives need to know my exact stance (which they know, in generalities).
I’m thinking of a rule of 7s: No more than 7 mins of CPR. No more than 7 days with a breathing tube down my throat. No more than 7 times 4 days with a feeding tube in my stomach. On day 28, pull every tube and IV and put me in hospice.
I might need a tattoo for that one???
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Gee whiz – you made me wonder if the staff in the colonoscopy clinic ask to see our Advance Directives before we get up on their table?!
Turns out that the rate of cardiac arrest is relatively low in those clinics during and after the procedure (4 per 10,000 patients) but 90% of all peri-procedural cardiac arrests that do occur happen to patients who have received propofol sedation.
So THAT’s the question we should be asking!!
I love that Rule of 7 you mention. Although that would be a BIG tattoo. . .
♥
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Hi Jill C,
I truly appreciate your viewpoint as I see things in somewhat the same light. I’m a listed transplant candidate and I believe in the viability of life. But my husband wanted a DNR as did my brother and I followed their wishes. As I did my mother’s. I have two sisters and they would want to hold on to me so I’ve given that to my doctor.
Being native, we have always known when it is our time but I don’t want to be left hanging when I still have a chance.
Take care,
Robin
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As a licensed dental assistant for 45 years, I was always certified in cpr every two years, but the need to use the knowledge never happened until 3 years ago, 4th of July, hot summer day.
Everyone is at the local beach and a little girl comes out of the water and says “what’s wrong with grandpa?” We all flew into action!
He’s alive and well. We broke his ribs, but he’s fine. I went to visit him a few weeks later just to see his blue eyes, alive, and not glazed over. Those dead eyes were haunting me afterwards even though I knew we saved him.
Who knows what we did, right or wrong. My turn at compressions didn’t go well as he was so much bigger than me and I kept sinking in the sand, so I kept to keeping his airway open and doing mouth to mouth. He’s alive and well, and I still can’t believe how a group of strangers worked so well together and saved a life.
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Hello Jennifer – you and your group DID save a life! What an unforgettable experience that must have been for all of you. You raise an interesting point about the rescuers’ response to resuscitation e.g. feeling that your turn at compressions “didn’t go well” because of the sand – but you DID succeed in keeping his airway open.
Speaking of rescuers’ response: I was just reading a CPR study from Spain on the common phenomenon called ‘rescuer fatigue’ which can begin to affect compression quality after only the first minute of CPR (!) not just due to physical effort but also to the “overwhelmingly emotional experience for rescuers, independent of the rescuers’ gender, age, weight, height or profession.”
Take care – and thanks for sharing that experience with us! ♥
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