Code blues: When is CPR not useful?

Over the course of my medical residency, I have developed a profound dread of ‘Code Blues,’ which occur when a patient experiences cardiac arrest and undergoes CPR. As a second-year resident, my feelings have shifted from anxiety about running a code blue to dread that if I’m not, I’ll likely be doing chest compressions.

Chest compressions should be easy. The person doing them simply has to stand at the patient’s bedside with her hands on the lower part of the patient’s sternum, repeatedly pressing about two inches into the chest at a rate of 100 to 120 times per minute. It requires only limited medical training. Yet, it’s become a feature in my recurrent nightmares.

I was recently called to a code blue in the ICU on a frail 82-year-old man with end-stage heart failure and incurable metastatic cancer. He had intestinal bleeding but did not want to receive blood products.

As the medical team assembled, we silently understood that this would be a “show code.” A “show code” is an effort to resuscitate a patient that is known to be futile. From the perspective of many medical professionals, it is a symbolic gesture to satisfy the societal expectation that everyone should die in the setting of a heroic, last-ditch effort at reviving them.

It represents the philosophy of preserving life at all costs that we have to some extent ingrained in us in medical school. It embodies the challenge of clear communication regarding goals for care. For families, it may provide closure and reassurance that everything possible was done to revive their loved one.

Stepping up to the bedside, I placed my gloved hands on the chest of this man I had never met. As I began chest compressions, I felt his ribs snap, one by one. A well-meaning attending once told me regarding CPR, “If you don’t break the ribs, you’re not doing the chest compressions right.” The most sickening experience in my medical training has been feeling an elderly patient’s osteoporotic ribs crack like thin twigs under my hands during chest compressions.

I had a choice of whether or not to look at this man’s face. If I don’t look, am I further dehumanizing him? Do I have a right to look someone in the eye as I am forcefully breaking his ribs in an effort to revive him – an effort everyone in the room knows will fail? If I look, how long will I have nightmares about his sunken, empty eyes and the bloody sputum being rhythmically ejected out of the corner of his mouth with every compression?

Suddenly, I realized I was the only person in the room who was physically touching the patient. No one else, whether they were giving medications, grabbing the ultrasound machine, or setting up the defibrillator, was in physical contact with the patient. I started to wish my experience in touching this man consisted of holding his hand in his last dying moments instead of crushing his sternum with my hands.

Eventually the code was “called,” meaning the family and the medical team agreed further resuscitation was futile. I took my hands off of the man’s chest and looked at his face one last time. I felt slightly nauseated. I exited the room, allowing his family to be with him. As I walked out, I felt a familiar sensation of bitterness and cynicism rising in my chest – another grotesque, graphic death in the setting of CPR that never had a chance of working.

CPR was integrated into mainstream medical care about 60 years ago. Its intention was to provide a stop-gap between when a person had a cardiac arrest and when EMS could arrive to get the patient to a hospital. CPR was never meant to be performed on sick, frail, elderly people in the final stages of their irreversible disease process.

CPR does nothing to improve a person’s underlying medical conditions. My patient with severe anemia, heart failure, and metastatic cancer, had he been resuscitated, would still have had severe anemia, heart failure, and metastatic cancer.

In addition to those issues, he would have a new host of problems from the CPR and resuscitation he had just endured. It has evolved to where everyone who dies in a hospital will have attempted resuscitation unless they have explicitly expressed a desire to die “naturally.”

Society views CPR as a heroic, jubilant act in which man triumphs over death, largely due to inaccurate portrayals of the process on television. In one study, characters on TV shows undergoing CPR survived the immediate arrest 75 percent of the time and made it to hospital discharge 67 percent of the time. This finding strikingly mirrors the perceptions of patients’ surrogate decision-makers in real life.

But these perceptions are woefully false. Studies have suggested that only about 22 percent of patients undergoing CPR in the hospital survive to discharge. And almost one-third have a clinically significant neurologic disability at that time. In fact, for patients with end-stage conditions like metastatic cancer or heart failure, the chance of surviving CPR drops to two percent.

From my perspective, my patient was a victim of the societal expectation that we should all die in an ICU, our ribs fractured by chest compressions, tubes and IVs hanging out of all parts of our bodies. In addition to CPR often failing, team performing the resuscitation.

Yet, we persist with these “show codes” for many reasons – families’ misconceptions about likely outcomes, the challenge and unpalatable reality of having frank goals-of-care discussions, and medical training that embeds within physicians the ideal that life of any quality trumps death at all costs.

-By Holland Kaplan, internal medicine resident at Baylor College of Medicine and graduate of the Medical Ethics Pathway.

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