By Daniel Schwester, MICP
I did not know him. But I have seen so many of them, I feel as if I do. And every one of them haunts me.
Pop Pop was in his late 80s when we met. I’d like to say we had a pleasant conversation. But that wasn’t possible. He had been found unresponsive in the bathroom of the memory care facility he lived in. A smear of brown fecal matter showed his unwilling transition from the toilet seat he was found on, to the cold tile floor. The mechanical CPR was in place, pistoning up and down as if it seemingly wanted to percuss a divot into his frail chest.
He looked so pale. There was an emptiness that I could sense in his body; as if any spark or spirit had left some time ago. All that remained was the procedural, almost banal effort we would have to put in to resuscitate him.
How long had he been down without blood flow, without life-giving oxygen to spare his vital organs and brain from irreversible death?
The staff didn’t know. He had been alive the last time checked, approximately 90 minutes ago. The memory care staff, mostly understaffed and overworked, knew that to speak freely may jeopardize their jobs, and maybe a lot else in this point in time; remained quietly reserved. Their policy was that CPR was given to everyone without a written DNR order, a policy likely promulgated by a director of nursing who was not there after 3 p.m. most days.
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The police officers dutifully continued the staff’s attempt to resuscitate, starting chest compressions and requesting the ambulance and paramedic unit immediately. Not starting CPR or continuing it could bring criticism and bad press; and we can’t have that. Besides, Pop Pop was still warm, and that must mean he’s not dead yet, right?
EMTs arrived on scene and took over. They placed the mechanical CPR device, monitored the AED, placed an oral airway and ventilated him well; just as they had been trained. No one noticed that the oral airway sat along Pop Pop’s tongue, his jaw hanging limply and somewhat stiffly open, in spite of their best efforts.
This was the scene that my partner and I arrived to. My partner, much younger and agile than I; wriggled her way past the doorway, equipment and other obstacles you find in a cramped bathroom and placed the monitor.
Asystole. Flatline. Nothing.
I went into the hall and spoke to the staff member who seemed to be in charge. Yes, there was an extensive history of dementia requiring memory care. No, we couldn’t pinpoint a time that Mr. X collapsed; he was found on the toilet. Yes, we could contact the next-of-kin.
“Did he have any advanced directive?”
“FULL CODE”, as the photocopied page signed by God knows who, the staff member hands me says, means we are to perform every possible measure to bring this person back from death.
No matter what.
We have been doing prehospital advanced emergency care in this country since the 1970s. The cardiac arrest survival rate in our country remains at around 10%, despite advances such as paramedicine, automated external defibrillation, massive efforts at CPR training, extracorporeal membrane oxygenation and the like. Literally billions of dollars and hours of research have been spent on the idea that we can overcome nature or God, if you believe; and bring people back to life.
We see it every night on television. Patients in cardiac arrest are treated heroically, sometimes with an actor emphatically stating, “Not on my watch,” as they again drag the recalcitrant soul back from wherever we go at the end of this existence.
And of course, they are back awake by the next commercial break; joking with family and friends as if they had a mole removed or LASIK. It’s just that easy, you see? If we just treat them, they’ll get better!
The reality is much more dismal. Older patients; and especially those with extensive co- morbidities, have much less chance of survival than the otherwise healthy 40-year old who collapses mowing their lawn. As you age, the chances get even worse — some papers quote about a 1% chance of any type of survival.
And let’s talk about “survival.” Have you ever been to an LTAC? It stands for long-term acute care, and it’s where non-neurologically intact patients who survive cardiac arrest end up. We in EMS know what they are, and the horrifying nicknames we give these places to get through the fact that they actually exist.
Remember the movie “The Matrix?” Remember when Laurence Fishburne told Keanu Reeves just what reality was? That we existed in a netherworld where we were used as organic power sources for some artificial intelligence? Human batteries?
Now take out the battery part.
These people are too sick to ever go home. Hug their loved ones. Say the things that matter. Make amends. They couldn’t continue to live without the tracheostomy in their throat, and the gastric tube inserted through their abdomen into their stomach to provide nutrition and oxygen. And for most of them, they will never get better. Ever. The only thing to look forward to is a long, slow, lonely decline until some infection or comorbidity catches up with them.
As this attempt at forcefully dragging Pop Pop back to this world continued, I took a quick 360-degree view of the scene. As team leader, my role was to see the field and direct care where it needed to go — make sure we were getting effective CPR, interventions being provided in a timely manner, and engaging the team in discussion about just what we needed to do to solve this problem.
As I looked around the room, I noticed something else. I noticed the faces of the people I was working with. I saw expressions of resignation and quiet frustration. As I announced the confirmed code status, I saw shoulders slump. Almost imperceptibly, but I could see it.
Another most likely futile resuscitation where there would be nothing but wrappers, leftover sharps, and the red bag to be dropped off at the station or hospital. Nothing to save.
We continued for a short while, then contacted our medical control doctor. She mercifully agreed that at this point, the chance of survival was nil, and called the attempt.
We cleaned Pop Pop up as best we could, tucked a sheet under his shoulders for some dignity, and slowly filed out of the room. Until called to do it again.
What the hell are we doing? And how do we break this cycle?
CPR as a stopgap
The current data tends to support the idea that CPR is a stopgap, a bridge for certain people until their arrhythmia can be fixed through intervention. It is not intended to stop or prolong the dying process; but that’s what it is for a lot of patients: a brutal way station to whatever comes next.
The fact is, modern medicine does a terrible job at end-of-life. It’s a topic no one really wants to discuss; but in the living room or bedroom of a person’s home with distraught family who want to know that “everything” was done, it can’t be a worse time. Statistics from the United States show the majority of healthcare money is spent at the end of life.
And in a profession where the yearly attrition rate is around 20-25%, are we inadvertently hurting our people and contributing to moral injury by making them do futile resuscitations on a regular basis, instead of honestly and compassionately evaluating patients for their effective response to our treatment?
I don’t know. But I remember a story from the World Trade Center after 9/11, when the rescue became a body recovery. I read that they would hide volunteers in the pile, so that the search and rescue dogs assigned to the site would find live “victims.”
The reason? The dogs were showing signs of depression from not finding anyone alive. Sound familiar? Why wouldn’t the futility of these resuscitation attempts not make an impact on our EMTs and paramedics?
So what do we do? I admit, a lot of this is out of our hands and in those of the primary and critical care clinicians who work with these patients on a regular basis.
We need more palliative care, and clinicians who understand that quality of life matters more than simply numbers.
We need to be honest with patients and their families about end-of-life issues, including a frank understanding of what it means to do “everything,” and what that may entail, good and especially bad.
When at all possible, we need to empower prehospital clinicians to objectively assess patients for their potential survival, and what that survival may mean. And sometimes, that means we should not attempt resuscitation if it is only prolonging the dying process. Clinicians also must be trained to talk with families at the scene as well as physicians who may have to answer the phone, so that there can be an honest discussion about what should be done.
We have to try to educate people about the realities of treatment; and we simply have to engage them to have honest discussions about how they want their end of life to go, and what should be done for them. If they don’t, someone else definitely will.
Pop Pop deserved better. He deserved dignity and comfort at the end of his life, and he didn’t get it. We can’t change that; but we can do better for others.
ABOUT THE AUTHOR
Daniel Schwester has been a paramedic since 2000. He has served in a variety of roles including education, field training, clinical supervision and active practice as a paramedic. He is the managing partner of Overrun Productions, LLC; and a co-host of The Overrun Podcast.
