Poor Outcomes From CPR and Ventilator Use in COVID-19 May Alter POLST Choices

The decision to initiate CPR has become more difficult.  We know that CPR substantially increases the risk of aerosolized SARS-CoV-2 and its transmission to health care workers (HCW) in the area of CPR.  For this reason, AMDA and other societies have given guidance on ways to reduce the risk, but these added risk reducing measures may delay initiation of CPR.  

This month, the Resuscitation Journal published an article on, “In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia”.  In this study from Wuhan, China, in a tertiary teaching hospital, outcomes for CPR were assessed.  In 136 patients, 89% had CPR initiated within 1 min.  Eighteen had a ROSC (return of spontaneous circulation), but only 4 were alive at 30 days and only 1 had a good neurologic outcome.  In our SNFs, where we don’t have rapid response teams and have less staff, and where most arrests are unwitnessed, the chances of a good outcome are even more remote.  

Given the increased risk to staff and the dismal outlook for a good outcome even with prompt CPR, should CPR even be an option during this COVID pandemic?

On April 22nd, JAMA published, “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized with COVID-19 in the New York City Area.”  The outcomes were assessed for the 2,634 patients discharged or died at time of study endpoint.  12.2% received invasive mechanical ventilation.  Of those receiving mechanical ventilation 72.2% were still on a ventilator, 24.5% had died, and 3.2% were discharged alive.  The mortality rate in those > 65 y/o that required mechanical ventilation was a dismal 97.2%.  This may be an overestimate of their mortality, since over half of the patients remained in the hospital at the end point of this study. However, it is consistent with other studies that indicate at least a 50% mortality in > 65 y/o requiring mechanical ventilation in the ICU.  In addition, these deaths are likely scattered over the 2-4 weeks of ventilator support commonly required for seriously ill COVID patients.  

Are your patients who wish full treatment status aware of the likely prolonged need for ventilator support, the high probability of ultimate poor outcome and marked reduction in functional status, the prolonged recovery for survivors, and the high burden of prolonged ICU care?

During the COVID crisis, the CCCC (Coalition for Compassionate Care for CA) has made available free of charge their excellent decision guides for CPR, Ventilators, Tube Feeding, and Artificial Hydration. https://coalitionccc.org/tools-resources/decision-aids/  These are available in multiple languages.  

CCCC has obtained a grant for assisting providers with COVID-specific advance care planning conversations and SNF-specific education and pilots.  Stay tuned for these added resources in the near future, which CALTCM will be contributing to.

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