ORIGINAL CONTRIBUTION cardiac arrest CPR do-not-resuscitate orders

Survival After Out-of-Hospital Cardiac Arrest in Elderly Patients From the University of Antwerp, Antwerp, Belgium. Received for publication July 15, 1991. Revision received February 11, 1992. Accepted for publication March 17, 1992.

Raf J Van Hoeyweghen, MD Leo L Bossaert, PhB Arsene Mullie, MD Patrick Martens, MD Herman H Delooz, PhD Walter A Buylaert, PhD Paul A Calle, PhD Luc Corne, MD Belgian Cerebral Resuscitation Study Group

Study objectives: Tostudy whether age of the cardiac arrest patient is related to prognostic factors and survival.

Study design: Retrospective analysis of a prospective registration of cardiac arrest events in the mobile ICUs of seven participating hospitals.

Study population: Two thousand seven hundred seventy-six outof-hospital cardiac arrests in which advanced life support was initiated. Cardiac arrests with a precipitating event requiring specific therapeutic consequences and with specific prognosis were not included in the analysis (eg, trauma, exsanguination, drowning, sudden infant death syndrome). Results: Neither resuscitation rate (23%) nor mortality caused by a neurologic reason (9%) was significantly different between age groups. Mortality after CPR of non-neurologic etiology was significantly higher in the elderly patient (younger than 40 years, 16%; 40 to 69 years, 19%; 70 to 79 years, 30%; 80 years or older, 34%; P< .005)and had a negative effect on survival in resuscitated elderly patients (P< .05). Elderly patients more frequently had a dependent lifestyle before the arrest (P< .025), an arrest of cardiac origin (P< .001), electromechanical dissociation as the type of cardiac arrest (P< .025), and a shorter duration of advanced life support in unsuccessful resuscitation attempts (r= -.178, P< .0001). Conclusion: Because survival two weeks after CPR was not significantly different between age groups, we suggest that decision making in CPR should not be based on age but on factors with better predictive power for outcome and quality of survival. [Van Hoeyweghen RJ, Bossaert LL, Mullie A, Martens P, Delooz HH, Buylaert WA, Calle PA, Come L, Belgian Cerebral Resuscitation Study Group: Survival after out-of-hospital cardiac arrest in elderly patients. Ann EmergMed October 1992;21:1179-1184.]

OCTOBER1992

21:10

ANNALS OF EMERGENCY MEDICINE

1 17 9/ 13

CARDIAC ARREST Van ltoeyweghon et a/

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INTRODUCTION CPR is a standard intervention inside and outside the hospital to restore failing circulation and respiration. Prompt initiation of CPR is recommended in witnessed cardiac arrest of u n k n o w n patients. The decision to continue or to withdraw advanced life support is based on clinical parameters and/or ethical considerations. Patients with a poor chance for successful outcome and a poor chance for an acceptable quality of life or patients suffering from a terminal ilh~ess might he resuscitated, and the process of dying and suffering might he prohmged.t In these cases, a statement of the patient's wish not to be resuscitated is required to prevent traumatic, futile, and expensive resuscitation attempts. Advanced age is an oft-cited argument to withhold CPR from a patient. Some authors suggest that, in the in-hospital setting, patients older than 65 or 70 years shmdd only be resuscitated in selected cases. 2,3 Outside the hosl)ital, CPR for the elderly has been described as rarely effective;¢ although, relevant literature suggests that age is not a negative predictor of outcome, z- t i Medicine is facing an increase in the prevalence of patients in their 70s and 80s. Because the prevalence of cardiac arrest is higher in these patients, 12 the dilemma of withhohling or withdrawing CPR in elderly patients will become even more acute than it is now. Most studies on the influence of age on survival after cardiac arrest have involved limited numhers of patients 3-(~-l° and lacked clarity and precision in reporting (eg, patient selection criteria, stratification for underlying disease).2, 5 The aim of this report is to determine whether advanced age couht he used in decision making before or during CPR by studying the influence of age nn prognostic factors of survival after cardiac arrest and to determine survival rate in age groups stratified for prearrest conditions. MATERIALS AND METHODS Seven emergency medical service (EMS) systems using a central telephone dispatch (dial 100) and a mobile ICU (MICU) team, participated and registered prospectively all cardiac arrest events during a five-year period (1983 to 1987). EMS systems were two tiered: The first tier consisted of a primary ambulance with basic life support (BLS) facilities; the second tier consisted of a rescue ambulance with an experienced emergency physician amt/or nurse, Outcome results between different centers were not significantly different. L~ The MICU team could he alerted by bystanders (using the 100 telephone dispatch system) or medieal professionals, i n nursing homes, do-not-resuscitate instructions were respected if ordered, and in these cases the EMS system was not activated. The registration form was completed by an MICU nurse or physician as soon as possible after the resuscitation procedure. The registration form and general results are described in detail in a previous report of the study group.14

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Only cardiac arrests confirmed by ECG monitoring where advanced life support (ALS) was initiated were included in the registration. Because only cardiac arrest cases where ALS was initiated were included in the registry, it is not known how many cardiac arrests have occurred where ALS was not initiated. A cardiac arrest occurring during transport by the MICU team to the hospital was considered an inhospital event hecause ALS and a medical team were available in the vehicle. In these circumstances, response times are virtually zero, as in the in-hospital situation. Patients suffering a cardiac arrest with underlying disease trauma, exsanguination, anesthesia, drowning, or sudden infant death syndrome were not included in this analysis. Arrests were considered to be witnessed when seen or heard by bystanders (last three years of registration) or when the access time of the event in the EMS system was less than one minute (first two years of registration). Retrospectively, witnessing of the arrest was significantly related to an access time of one minute or less. 14 Prearrest health state was recorded according to the classification of Jennet and Bond. is Access interval was defined as the interval between collapse and the moment the EMS system was alerted. This interval was estimated by bystanders. 16 Response interval of BLS was defined as the interval between collapse and initiation of basic CPR either by bystanders, ambulance personnel, or the MICU team. Response interval of ALS was defined as the interval between the collapse and the initiation of ALS by the MICU team. Response interval of BLS was estimated by bystanders or ambulance personnel. Response interval of ALS and duration of ALS were estimated by the MICU team. The telephone dispatch system recorded accurately when the EMS system was alerted, when the MICU team left the hospital, and when it arrived at the scene of the arrest. The type of cardiac arrest on arrival of the MICU was classified as ventricular fibrillation (including ventricular tachycardia causing collapse), asystole, or electromechanical dissociation. A CPR attempt was considered a failure if the patient died before admission to the hospital. A CPR attempt was Table 1. Effect of age on outcome after cardiac arrest

Age Groups(yr) 80 To~l (N =327) (N =2,755) No.(%) No.(%)

50 (23) 27(12) 8 (4)

318 (23) 127 (9) 60 (4)

196 (24) 77 (9) 59 (7)

61 {19) 21 (6) 21 (6)

625(23) 252 (9) 148 (5)

NS NS