CPR decisions in a pandemic

In lockdown and isolation, boredom and anxiety have given us an insatiable hunger for connection to the rest of the world. We’re voraciously consuming news media and social media, trying to wrap our heads around Covid-19 and how it might impact on us – our country, our community, our family. Unfortunately, while we’re comfort-eating our way through this online media, we can inadvertently consume some pretty awful ”junk”.

Recent media claims around resuscitation decision-making by ambulance personnel are an example of this junk: headlines may look tasty, but there is no substance to the articles. I know this because I have spent the past six years researching resuscitation decision-making by ambulance personnel in New Zealand.

Let’s start with some clear definitions relating to resuscitation. Cardiac arrest occurs when the heart suddenly stops pumping blood around the body. When people go into cardiac arrest, they become unconscious and cannot move or speak, although they may twitch for a few seconds and gasp for a minute or more. If cardiac arrest is caused by a problem with the heart – like a heart attack – this is called a primary cardiac arrest. With immediate cardiopulmonary resuscitation (CPR) and a defibrillator, the heart may start to beat again. Usually, the patient will then require further care at the hospital to fix the underlying problem.

Sometimes the heart stops because other organs in the body have failed. A secondary cardiac arrest may come at the end of advanced or severe illness or injury. CPR rarely gets the heart beating again, in these circumstances. And CPR does not reverse the critical illness or injury which caused other organs to fail.

When do ambulance personnel provide CPR?

In New Zealand, ambulance personnel attend more than 4000 people in cardiac arrest each year. Often, Fire and Emergency New Zealand staff or, particularly in rural areas, local volunteer emergency responders trained in CPR will also attend. In more than half of cardiac arrest patients, it is clear that the person has died and ambulance personnel do not attempt CPR.

Even where ambulance personnel attempt CPR, it is rarely successful. On average, for every10 patients in cardiac arrest attended by ambulance crews, around eight are ultimately declared dead, at the scene. Two will make it to the hospital with a pulse, but one of these will die within the next 30 days. Most of those who recover from cardiac arrest are adults who have few comorbidities and have had a primary cardiac arrest – most commonly, a heart attack.

So, will I still get CPR in the pandemic?

CPR is not a cure for ordinary dying. It cannot reverse the impact of advanced aging, mortal injury or end-stage disease. New Zealand paramedics are highly-trained experts and have clear clinical guidelines and access to support for challenging clinical decisions. My research demonstrated that paramedics can find it difficult to enact a decision to withhold or terminate resuscitation, and will start or continue if there is any chance at a good outcome. So the answer is yes, you will still get CPR if there is any chance it will be effective. This has not changed.

What is different is that rescuers attempting CPR on patients with Covid-19 need to wear full protective gear to avoid becoming infected. The nature of resuscitation means rescuers have to get very close to the mouth of the patient and use equipment and procedures which increase the risk of spreading the virus. In New Zealand, ambulance personnel are supported by clear guidelines, which prioritise the best interests of the patient. If a patient with Covid-19 is so sick that their heart stops, it is likely due to severe pneumonia and widespread catastrophe in their bodies, which CPR will do nothing to resolve.

At this point, I am optimistic that New Zealanders will continue to flatten the curve of Covid-19 infection so that our health systems are not overwhelmed, and healthcare rationing will not be required. We are fortunate to live in a country with universal healthcare, but universal does not mean unlimited or on-demand. New Zealanders have the right to health services of an appropriate standard and freedom from discrimination. This does not mean we have the right to demand interventions which are not likely to be of any benefit or may even cause harm.