Resuscitation techniques have come a long way. Just a few years ago, there were only a handful of hospitals using therapeutic temperature management (TTM), also known as therapeutic hypothermia, to treat cardiac arrest patients. Now, it’s becoming a standard tool of resuscitation, but studies show ‘cooled’ patients with good outcomes have longer code times than the traditional practice of ending resuscitation efforts after 20 minutes. So how do physicians know when to call a code?
In a paper entitled “How long is long enough, and have we done everything we should?—Ethics of calling codes,” published online last month in the Journal of Medical Ethics, senior author James N. Kirkpatrick, MD, assistant professor in the division of Cardiovascular Medicine and department of Medical Ethics and Health Policy, and others explored this very issue.
“We looked at several recent studies that suggest patients tend to do better with longer resuscitation times,” says Kirkpatrick. He says that even though standard practice is to stop resuscitative efforts after 20 minutes, “with all the new technologies we can have available, that’s probably no longer valid.”
It’s no longer as simple as assigning a duration of time for calling codes; in many cases, it’s more about getting to know a patient’s resuscitation wishes and customizing treatment accordingly.
Think about it this way: When a pregnant woman is planning for the birth of her child, she has extensive conversations with her family and her doctor about her birth plan preferences. But since childbirth is inevitable for a pregnant woman, it’s somewhat easier to plan for the decisions that come with it. On the other hand, cardiac arrest is far from inevitable for most people, and therefore the motivation to think through a resuscitation plan may be lacking.
“It’s about getting a general sense of both the patient’s and the physician’s perspective — understanding the patient’s values and goals, and then balancing them with what’s medically reasonable,” says Kirkpatrick.
Among the issues addressed in the paper are improved outcomes with longer resuscitation times and new technologies that have changed the field of resuscitation. These technologies include TTM, but also emergency cardiopulmonary bypass (ECPB) for patients not helped by CPR. These technologies are not right for everyone, and may even be harmful for some. That is why it is important to consider what is right for each patient. Thinking about it ahead of time should help in this process.
So the question becomes: can a physician really say to a family, “we did everything we could,” when in fact they simply stopped resuscitation efforts after 20 minutes? Maybe they should instead say, “we did everything we thought was medically appropriate.” And as a patient, how much is too much? What if resuscitation has a really low chance of bringing someone back to an acceptable quality of life? When is enough really enough?
It’s a delicate balance with no shortage of nuance, but it does beg the question: Have you talked with your doctor or family about your resuscitation wishes? It may just be the right time.