What is it the role of resuscitation at the end of life?

Resuscitation has radically changed the way we respond to cardiac arrest (the heart not pumping) but it hasn’t changed the reality that eventually, everyone dies. Presenting at the recent New Zealand Resuscitation Council Conference, I asked: What is the difference between cardiac arrest and death? And how do we continue to strengthen the chain of survival whilst also acknowledging that resuscitation is sometimes unwanted, unwarranted or unsuccessful?

Whilst I was pleased to be invited to speak at the #NZResus2022, I was conscious that my plenary stood apart from other presentations, which were squarely focused on survival. I do know a bit about resuscitation – I’ve been learning about it, teaching it and doing it for decades. I’ve been privileged to be part of the chain of survival in prehospital, emergency and intensive care contexts. I’ve also been researching, thinking and writing about death and dying in emergency settings, particularly resuscitation decision-making by paramedics. This session was a a provocation. A challenge. A chance to consider questions without having all the answers.

For most of human history, cardiac arrest has been synonymous with death. Everyone’s heart stopped once, at the end of their life.

In the latter half of the 20th Century, Cardiopulmonary Resuscitation (CPR) was developed. Return of spontaneous circulation (getting the heart to beat again) after cardiac arrest was a miraculous achievement for resuscitation science. In only a few decades we went from powerlessness in the face of cardiac arrest to empowering lay responders to save lives

Today, resuscitation is attempted in an unknown fraction of cardiac arrests, every year. Some of those people will survive – some for hours or days, others for many years. Resuscitation is a powerful tool, but eventually we will all still, ultimately experience one fatal cardiac arrest. Positive depictions of resuscitation in the media have contributed to societal expectations that CPR is a panacea for death and will immediately restore the patient to full function. With people living longer than ever with more complex comorbidity, some are questioning the wisdom of defaulting to resuscitation in all cardiac arrests. Sometimes it may be appropriate to consider if CPR is unwanted or unwarranted. At the very least, it should be acknowledged that even the best resuscitation efforts will sometimes be unsuccessful.

The first principle of CPR is the patient must be salvable. CPR is indicated for the patient who, at the time of cardiopulmonary arrest, is not in the terminal stage of an incurable disease.  Resuscitative measures on terminal patients will, at best, return them to a dying state.”

(Jude & Elam, 1965)

Questions for those who teach CPR or mentor health professionals who may be involved in resuscitation efforts:

Are we preparing first responders for unsuccessful resuscitation?

How can we better prepare & support health professionals to respond confidently, compassionately and competently, when resuscitation is unwanted, unwarranted or unsuccessful?

Is it important to differentiate between sudden, reversible cardiac arrest and cardiac arrest at the end of life?

Natalie’s PhD explore how paramedics from Aotearoa, New Zealand decide to start, stop or continue resuscitation. You can read more about her research and resulting model of prehospital resuscitation decision-making here.

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