Have you ever thought of what your last moments might be like? As much as most people would like to have a peaceful and comfortable death, life is unexpected and we do not have much control over how we would pass away. This is what Resuscitation Status aims to address.
What is Resuscitation Status?
Resuscitation Status is a medical order that communicates to medical providers how you would like to be managed in a life threatening emergency situation. It is created following a discussion between the patient (or substitute decision maker) and the medical practitioner, and is ultimately a medical decision. This discussion typically happens on admission to hospital.
No matter how healthy you may be, unexpected medical emergencies can occur that lead to you being unable to communicate your wishes for resuscitation. The Resuscitation Status can be revisited and revised at any time, although this usually only happens when there is a change in the clinical situation.
As a general rule of thumb, it describes your wishes regarding Cardio-Pulmonary Resuscitation (CPR), admission into an Intensive Care Unit (ICU) and the kind of treatment that you will receive in ICU, and whether you would be for MET calls. Given this, it is important that we talk about CPR and ICU.
What is CPR?
CPR is a medical procedure involving chest compressions, ventilation and if required, cardiac defibrillation. The chest compressions ensure that blood continues to flow through the body, while ventilation ensures that you continue to receive oxygen whilst cardiac defibrillation helps restart the heart if required. You may have seen depictions of this in movies or TV dramas, where a character who is thought to have died is immediately brought back to life following administration of CPR by a medical provider.
If CPR brings a person back to life, shouldn’t everyone receive CPR?
In order to answer the above question, we need to understand what CPR is designed for and what the process of CPR actually entails. There are 3 reasons why CPR would not be appropriate for everyone.
Reason 1: CPR only fixes a specific problem
CPR was designed to resuscitate patients who have died as a result of a cardiac arrest. This means that it would not be effective in resuscitating patients who have died from infections, cancer or other causes.
One way to think about it is that there are many different medications that treat different medical conditions. Antibiotics do not fix high blood pressure, and anti-hypertensive medication do not fix bacterial infections. Likewise, CPR is not a solution to every cause of death. As a result, when patients are extremely unwell as a result of severe infection or progression of terminal cancer, medical practitioners may choose to make the patient “Not for Resuscitation” because performing CPR will not provide any benefit to the patient.
Reason 2: CPR can be very harmful to you
Apart from potentially not providing any benefit for the patient, CPR can actually be very harmful to patients who receive it. In order for chest compressions to be effective, the CPR provider has to break your ribs and this will put patients in a lot of pain if they are successfully resuscitated. Patients may also end up with a hypoxic brain injury (and become severely disabled) if CPR takes a while before they are resuscitated. Even if patients are successfully resuscitated, many patients pass away shortly after.
Reason 3: CPR is not as effective as you think
Furthermore, the success rate and eventual survival rate of CPR is lower than you would probably expect. A recent retrospective cohort study in the United States found that 66.9% of patients who received CPR in hospital achieved “Return of Spontaneous Circulation” (RoSC, also meaning successful resuscitation) with only 22.6% of these patients surviving to their discharge from hospital.
Given that CPR does not benefit everyone, provides harm to almost everyone and does not always lead to a positive outcome, CPR is not a procedure that should be provided to everyone.
What is ICU? What happens in ICU?
The Intensive Care Unit (ICU) is a ward in the hospital that is designed to be equipped to manage the sickest patients in hospital. Patients typically end up admitted into ICU either as protocol following a high-risk procedure (e.g. open heart surgery) or because they have had a severe clinical deterioration on the ward.
Although the ICU is able to perform many life-saving procedures in order to keep patients alive, there are three categories that patients are usually asked about when discussing resuscitation status.
Category 1: Closer Monitoring
Since patients who end up in ICU are more acutely unwell, they tend to get observations performed by nursing staff more frequently than they would on the ward. However, closer monitoring also involves the use of more invasive methods of monitoring your vital signs. One such example is the insertion of Arterial Lines to measure your blood pressure. If patients would not like this, then they would not be suitable for an ICU admission as the level of care that they prefer can be done on the ward.
Category 2: Inotropic Support
An inotrope is a medication class that raises a person’s blood pressure. When a patient has severely low blood pressure, they may end up with organ failure due to insufficient blood reaching their organs. Inotropes are used to maintain a patient’s blood pressure in the event that intravenous fluids are unable to keep them high enough to prevent end organ failure. The reason that inotropes can only be administered in ICU is that they can only be given through central lines that can only be managed by ICU level staff.
Category 3: Ventilation
Finally, patients get asked about ventilation. Ventilation has to do with helping one to breathe and ensuring that their bodies receive sufficient oxygen. There are two types of ventilation: Invasive Ventilation and Non-Invasive Ventilation. Invasive Ventilation typically refers to the process of Intubation, where patients are sedated and have a solid tube inserted into their windpipe and connected to a machine that helps them to breathe. Non-Invasive Ventilation comes in a three main modalities: High Flow Oxygen, CPAP and BiPAP. As the name suggests, Non-Invasive Ventilation is less invasive than its counterpart, and patients are not typically sedated in order to receive Non-Invasive Ventilation.
MET Calls
A Medical Emergency Team (MET) Call is a formal call for help from more doctors and nurses. It is usually called by a doctor or nurse when a patient is actively deteriorating. The makeup of the MET team differs from hospital to hospital, however it usually includes a doctor from the ICU who will assess whether the patient requires ICU admission.
With regards to Resuscitation Status, most patients would be for MET Calls. The only exception to this would be patients who have been put on End of Life Care and are expected to pass away shortly.
Ward Based Measures
If a patient is not for CPR or ICU admission, then they would be deemed to be for “Ward Based Measures Only”. As the name suggests, it refers to receiving medical care that can normally be provided in the ward. Examples of this include the administration of intravenous (IV) antibiotics or IV fluids.
Advanced Medical Directives and Lasting Power of Attorney
An Advanced Medical Directive (AMD) is a legal documents similar to a resuscitation status, with the difference being that they are filled out prior to a hospital admission. You can find out more information about this from the MOH website here.
A Lasting Power of Attorney (LPA) is a legal document whereby you appoint one or more persons to act as a substitute decision maker for you if you lack the mental capacity to make your own decisions. Some examples where this could happen include progression of dementia or delirium secondary to infection. You can find out more information about LPAs here.
In Singapore, both AMDs and LPAs fall under the Mental Capacity Act. The Ministry of Social and Family Development (MSF) has prepared an easy-to-read document regarding this that you can find here.
Special Considerations to be Aware of
Please remember that the Resuscitation Status takes the form of a medico-legal document. Having a tattoo that says “Do Not Resuscitate” is not legally binding and does not stop a medical provider or first responder from performing CPR.
A “Do Not Resuscitate” order on a legitimate Resuscitation Status document does not hold up in the event of an attempted suicide. A medical practitioner who follows the “Do Not Resuscitate” order in the event of an attempted suicide can be accused of assisting with suicide and this is against the medical code of ethics.
Closing Thoughts
Now that you know what resuscitation status entails, it would be good to think about what you would like to have done in the event of a medical emergency. This will greatly help medical providers in providing the best possible care for you in hospital, even in the event of a medical emergency.
References
https://www.bmj.com/content/384/bmj-2023-076019 (Okubo 2019, effectiveness of CPR)
https://www.moh.gov.sg/seeking-healthcare/advance-medical-directive
https://www.healthhub.sg/live-healthy/lasting_power_attorney_lpa
