Peter LermanInformed consent is one of the pillars of modern medical care. The most foundational principle is patient autonomy, which cannot stand without the support of informed consent. 

However, there is one medical procedure that does not require consent. There is only one condition for which medical intervention is undertaken with “presumed consent”—cardiopulmonary resuscitation (CPR) for asystole (cardiac arrest).

The situation presents a challenge for the skilled nursing community because new admissions are being asked in advance about a hypothetical situation: Do residents prefer staff to perform CPR for them should they go into cardiac arrest? 

Skilled nursing professionals are asking for the “consent” in advance, but it turns out they may be doing a poor job of the “informed” part, according to an article by Lindsey Ouellette in the American Journal of Internal Medicine, October 2018.

Staff have the benefit of not having to presume residents’ consent, unless they opt to not declare their wishes, but staff also have the responsibility to give complete and accurate information in a form residents can understand.

Attempting to Resuscitate

First, consider that the choice offered is somewhat deceptive when presented as “Do Not
Resuscitate” (DNR) vs. “Full Code,” a binary choice that implies staff can and will resuscitate a patient if they so choose, or residents may make a declaration in writing instructing staff not to resuscitate. 

In the first case, staff actually may be able to resuscitate patients. But far more likely is the possibility that staff will not be able to resuscitate them. In light of this, the American Heart Association in 2005 changed its preferred terminology from “Do Not Resuscitate” to “Do Not Attempt Resuscitation.” Thus, DNR became DNAR, according to an article by Joseph Breault, MD, in the Ochsner Journal, November, 2011. All that staff can offer to do is attempt resuscitation.

A Clouded Perception

Second, staff commonly ask residents to choose their code status without giving them the information they need to give informed consent. Researchers have found that members of the public believe that CPR is successful in 66 to 75 percent of instances, report Lindsey Ouellette et. al, in the American Journal of Emergency Medicine, October, 2018. They say that their estimation is based on what they have seen in TV shows such as “Rescue 911,” “ER,” “Chicago Med,” and “House.”

Other researchers have watched hundreds of episodes of these shows and analyzed the percentage of successful resuscitations depicted. “Rescue 911,” for example, has a success rate of 100 percent; other dramas have rates in the 65 to 75 percent range, according to an article by Jaclyn Portanova et. al, in
Resuscitation, November 2015. These outcomes could hardly be less reflective of the real-world results, for which few surveys report success even as high as 20 percent for members of the general population.

Additionally, CPR success rates for elderly persons are, in every study, significantly less. In some studies the success rate for persons in their 60s is about 8 percent, declining to about 3 percent as patients pass 80 years of age, according to the Institute of Medicine’s Consensus Report in 2015, “Strategies to Improve Cardiac Arrest Survival: A Time to Act.” 

Other studies place success rates even lower, so it is important to try to align perception with reality.

Injuries in the Elderly

There is also the consideration of the injuries commonly sustained by patients who are receiving CPR. There is a likelihood of broken bones in the chest from the physical force necessary to administer effective chest compressions. Also, there is often anoxic brain injury from the lack of circulation during the time there was no effective heartbeat. Both of these are more likely and more severe in older patients, and both are harder for elderly persons to recover from.

“It is violent,” said David Davis, MD, of Christian Hospital in St. Louis, quoted in The New York Times on Aug. 10, 2012. “If you don’t do it hard enough, you can’t move any blood. But if you do [thrust hard enough], you’re going to break the ribs and maybe the sternum.”

CPR, when administered properly, requires a provider to lean over the patient with both arms straight, elbows locked, with the heel of one hand on the patient’s sternum, the second hand is on top of the first. The provider must push down sharply on the sternum with sufficient force to compress the chest two to two and a half inches at a rate of 100 times per minute.

When presented with the factual information of real-world outcomes versus the fictional television outcomes, one study found that fully one-half of patients elected to change their code status from Full Code to DNAR. This demonstrates that providers have been doing a poor job of informing their residents about the choice they are asking them to make.

Bringing CPR Into Reality

It can be difficult to begin the conversation with patients and families regarding this decision. Few outside the health care professions are conversant with the terms of the practice and the various—sometimes complicated—situations that might present themselves. They don’t know how to talk about it or even how to think about it. In addition to the misperceptions regarding successful resuscitation, in some patients there is a suspicion that selecting DNAR means their caregivers won’t do their best to make them well or a mistaken notion that the caregivers might consider them patients who “don’t really want to live.”

Simply handing someone statistics and reprints of studies and analyses can be off-putting. It can also demonstrate a lack of empathy. A sincere and direct conversation can help a patient arrive at the choice that suits their goals and beliefs.

During this give-and-take, staff have the opportunity to present a clear-eyed view of the options and most likely outcomes. Excellent guides for “The Discussion,” which help staff educate patients and help patients express their inclinations, are available online at the or from the website of each state’s MOLST/POLST initiative. Printed material is also available from these organizations for patients who want to read more about it.

Ellen Casey, administrator of the Wilton Meadows Health Care Center, a skilled nursing facility in Connecticut, is happy to be on board with an initiative to have new admissions and current residents become better educated on the real-world possibilities and results of CPR for older patients.

“Everyone has the right to be fully informed before they make any health care decision,” she says.
“This includes end-of-life decisions. We are grateful to have the opportunity to provide excellent care for people at a very special time in their lives. Advanced care planning allows everyone on the health care team to provide that care in the best possible way,” she says.

Providers can easily do a better job of assisting patients in making the choices that can help them get the end-of-life care they want for themselves. Should patients learn the probability of surviving CPR and still want it provided, there is no question that it should be provided. Providers should still rely on both the foundation of patient autonomy and the pillar of informed consent. All providers are encouraged to work a little bit harder on the “informed” part.
Peter Lerman, BA, RRT, is the staff respiratory therapist at Wilton Meadows Health Care Center in Wilton, Conn. He is registered with the National Board for Respiratory Care and licensed in the states of New York and Connecticut. He is also a Red Cross-certified CPR Instructor for Health Care Workers and a Certified COPD Educator. He can be reached at