 Thank you very much. Our next speaker is Dan Browner, Associate Professor of Medicine here at the University of Chicago, who went to medical school at SUNY Syracuse and did his residency at Cook County, where he was Chief Resident, and he's interested in developing better ways to communicate and evaluate the decision-making capacity of persons with dementia using linguistics and discourse analysis. And his research interests include the historical study of resuscitation, cardiac arrest, and DNR, about which we're going to hear. Now, thank you. Thanks, Dan. Everyone hear me? Can you hear me? Yeah, good. I want to thank Mark and the Colleen Center for being a real intellectual home for me for the last almost 20 years. Now on to my talk. How many of us have been exasperated by the family who wants us to do everything for their loved one, despite the fact that there's not much we can actually do that will help? I hope to show today that this exasperation is misplaced because it is us who created this option and we who continue to routinely offer it. To understand where the scripts that drive current performances of the negotiation of care for the very old and gravely ill, my methodology is historical analysis, which involves a close reading of the mostly medical literature as well as articles from lay press from the past. In order to appreciate how everything came to be presents a long and interesting history and way beyond my 15 minutes. So I will zoom into what I consider to be the most compelling pieces of this history and distill that. We need to go back in time to a time when before resuscitation was the default for everyone whose heart stopped. When cardiac arrest, a condition contingent on its treatment could only occur in the operating room right before resuscitation became the first and quintessential embodiment of everything. This takes us to the 1950s, which I consider to be a really neglected decade historically. Because it was during this time that our current indications for resuscitations were developed. We are currently operating under a framework that was developed in the 1950s at a time when resuscitation meant ripping open the chest and directly massaging the heart. And this is really the moment of the ascendancy of resuscitation, illuminating the fact that it was really never about the efficacy of specific techniques, but about the potential for success. It was during this time that the idea of universal default resuscitation was born and the campaign to adopt it conceived. So it's essential to look at the circumstances that led to the broadening of the indications, asking what were these forces, medical, social, political, economic, which will hopefully inform us now in the future at our present time to look at the possibilities for improving the current situation. So we're talking about a procedure that was developed in the actually in the 1880s, but really the first successful cases were done in the turn of the last century. This is a New York Times article describing how life apparently extinct has been renewed, or shall we say the dead themselves have been brought back to life. And this is a description of open resuscitation done in the operating room at the turn of the last century. So this was a procedure that was fairly uncommon for some time. You see here I picked just three papers here. In 1906 there were 40 cases in the literature. This is a paper that reviewed all the cases. In 1945 another paper looking at the history of resuscitation reviewed all the cases that had been reported in the literature and this numbered 148 at that time. Of course this is a slight underestimation because everybody's not reporting all their attempts, but this gives you sort of an idea. In 1953 a paper was published from a paper that was presented in 1952 that described 1200 cases which you can see as a marked increase in the number of people undergoing resuscitation. In the 50s really see a marked increase in this number. We see the initiation of courses in resuscitation and a group of advocates who were very, very excited about resuscitation because it worked. And their goal in reporting their results from my review of the literature was not so much to determine whether the procedure worked or not. They were convinced that it worked. They had seen it work in their own hands. If not to bring the patient back to life, at least to restart the heart, which was the beginning. And so their real intent was not to prove that it worked but to convince other physicians and the public that it worked and that there was a vast potential for it to work better. One of the interesting things in which I don't really have time to go into specifically here is that the ways we talk about science and what was happening at the time have vastly changed since that time in the 50s when they were reporting their results. And what we really see here is an evolution from case reports to outcome studies. The initial reports talking about cardiac resuscitation were reports usually of success because most people don't want to report their failures about how it worked in the operating room starting in the early 1900s. But slowly this changed into studies which were actually looking at outcomes and percentages. And what was really interesting about looking at these papers is what information do these authors choose to include and not to include because the standards of the time are really different. And this becomes really critical in the 1950s when resuscitation, the decision is made to move resuscitation out of the operating room. This is really a really important decision that I don't think people really appreciate the import of it because it really led to a development of indications for resuscitation to the indications that we have today. So this is a picture of a crash cart that was used at Bellevue by Stevenson, the author of the paper that reported the 1200 cases in 1953. And this is a crash cart that he developed. And what they did, he developed a course and they taught the residents at Bellevue in the early 50s how to resuscitate patients on the wards. And they let them loose. And they basically started resuscitating pretty much everybody who died on the wards. And he did report the results of the study as part of this paper. Now, again, the 1200 cases here is actually a worldwide registry that he got from a lot of physicians and it includes the Bellevue experience. And the Bellevue experience is mostly in the operating room, but 13% were outside the operating room. And interestingly, what he talks about in this paper and in subsequent books on cardiac resuscitation, it's not so much what the patients had, what their conditions were, but where the resuscitation occurred. Because location really is the key here. The first place is the operating room and then once we get out of the operating, where does it happen? And so he breaks it down by location. And they actually have a pretty good success rate, so 24% success rate for resuscitation outside of the operating room, this 13% of the cases here. But he never really breaks it down as to which locations were better or what the conditions were the patients have. And interestingly, there comes a critique, which I think is a really important paper that most people, I dare say have not read. This is a paper that was written by someone who was clearly inspired by Stevenson's work. And he tried to replicate his work of resuscitating people outside of the operating room using this technique. And what he found was a pretty abysmal. He was able to resuscitate one person out of 24. And what he found, and that person was someone who was in the actually radiographic suite, who had undergone a bronchography, which was basically they would blow oil impregnated with iodine into people's lungs to take pictures of their lungs so they could visualize their bronchogram before the age of CAT scans, obviously. And that was the patient that resuscitated. And when he delved into what the other physicians were doing, a critique of the other reports, he found that in the vast majority and just about all the patients who were successfully resuscitated, he found that a physician had usually performed the study which precipitated the arrest. So this technique works. It definitely works. The only problem with it is that it only works if the doctors have killed you first, which is not something that is not something that's really made clear in any of these papers. So despite the abysmal results of most of these studies in terms of resuscitating patients who had other illnesses who were not undergoing niatrogenic deaths, there was a sense that the indications needed to be very broad. In part because of the necessity of getting in there quickly, time being an important factor, the analogy of the fire drill is almost used, is often used. And Claude Beck, who's one of the real fathers of resuscitation, I think probably the most responsible for how resuscitation looks today, made this statement, which I think was pretty prescient. The possibility for successful resuscitation are greatest in patients who do not have primary diseases of the respiratory or circulatory systems. And previously he had advocated that those people should not be resuscitated. But he sort of changes his mind beginning in the 1950s and goes on to say, however, successful resuscitation is possible even in the presence of disease. And this is a major trope we see in lots of resuscitation literature is that this notion of uncertainty. And so it should be attempted even though one anticipates that it will be futile. At the worst, the surgeon may gain valuable experience from the attempt. And so we see here sort of an early rationalization, I think, for the start of what would become universal default CPR. So by the time the 1960s come, and this paper is published in July, when closed chest compressions were rediscovered, and the first 20 patients reported, we see here a 70% success rate. Again, because they're using the same patients that the surgeons had been attempting to resuscitate before. These are patients who were either in the operating room, who were getting cardiac casts. The vast majority of them had diagrogenic complications. And that was why they had, you know, a 70% success rate, which is obviously never been replicated. Now, the same group that started using closed chest compressions realized that as you broaden the definition, the indications for resuscitation, you need to therefore change the actual definition of what constitutes cardiac arrest. And they actually say it specifically, the term one supply only to sudden death associated with anesthesia and surgery. But now, cardiac arrest is now the sudden and unexpected sensation from whatever cause of circulation, from the unexpected sensation from whatever cause of circulation producing cardiac activity. Of course, people have talked the notion of what's unexpected. You know, that's a very obviously dependent on the person, somebody else's expectations. And that's been one of the controversial things about that was initially discussed about cardiac arrest. But now, we don't really even use the unexpected. You know, your heart stops, you have cardiac arrest by definition. I would say the third factor, the final, the force in the development of what I see as universal default resuscitation, was happened in the 60s. And with the outlay of large amounts of government dollars into the infusion of large amounts of government dollars into the health care industry. And I would suspect, and I'm looking forward to studying this further, that a lot of the health care dollars that were put into medicine in the mid 60s were used to treat cardiac arrest. That this was a very sort of expensive condition that required very high tech and very expensive medical care. And that a lot of the money that came in at this moment would go into that pursuit. That's making that treatment of cardiac arrest very much a part of health care. And I would say at this point then, with the establishment of a default CPR, that resuscitation really became everything. Everything being a treatment without really an expectation that it would actually help this particular patient. And I think starting in the late 50s with the development of sort of the universal notion of resuscitation that we see a conceptual shift in the locus of interest in the doctor-patient relationship. That's very deep. And I think it's a very important shift. And the shift is from the patient, the embodied individual whom you are caring for at that moment. And the question, what is the best for this patient at this moment? And it shifts to this sort of broader concept of patients. And that's the group of all patients and potential patients. And it's more of a theoretical construct based on a belief in the awesome power of resuscitation to help them. And so it's sort of this belief that resuscitation is a good thing in general that really changes how we interact with the patient that we're taking care of at that moment. Of course, DNR comes along in the 70s. And I see that as an attempt to fix this paradigm. And I think what it was was a really well-intentioned effort to transfer focus back to the patient in front of us. What's best for this patient at this moment? However, that's the positive part of it. I think there are several problematic aspects of it as well. It supports the current paradigm in which we have these defaults. It tends to limit the focus to a future response to a procedure that in the vast majority of our patients won't help. And what I think it really gets in the way of is diverting attention from care in the present. This notion of care, of advanced care. And people tend to act and to think in very binary ways. So the opposite of everything becomes nothing. And so very often people will shift that, will see the definition and it makes sense that DNR would then go on to mean that. Even though everybody knows it shouldn't mean that. Very often, even though we know it doesn't, there's a lot of empirical evidence that shows that people do get less care when they are DNR sometimes inappropriately. I'd like to use the analogy of selling protection, which I'm not going to get into. And what I would call for at this juncture after making this sort of hysterical analysis, is that, is a refocus on care in the present for patients. And this, this requires a sort of a radical, alteration in sort of the way we talk about the potentials for treatment and truth telling with our patients. And I think DNR needs to be sort of the last question that we bring up with our patients.