 I'm delighted to welcome you on behalf of the McLean Center for Clinical Medical Ethics to today's lecture in our series on end-of-life care. Next Wednesday in this room, on March 11, Professor Nadia Sawicki will be giving a talk on, the title is, Tort Liability in End-of-Life Care, and that will be the last talk of the winter quarter. We then will resume this series, Taion, do you know what date? I think the first Wednesday in April? Yeah. It's now my pleasure to introduce today's speaker, Dr. Dan Bronner. Dr. Bronner is an associate professor of medicine, the director of the geriatrics fellowship program, and the medical director of Montgomery Place Health Care Pavilion. Dan earned his MD from State University of New York at Syracuse, completed his residency at Cook County Hospital where he was chief resident. Dan then completed fellowship training at the University of Illinois at Chicago and at Cook County. Dr. Bronner's academic interests include interdisciplinary approaches to medical and ethical issues with a primary focus in geriatrics. He has been interested in the effect of dementia, in the care of other illnesses, and in the ways in which linguistics can inform novel approaches to improve communication with patients who have dementia. Currently, Dan is developing a method for evaluating decision-making capacity in patients with dementia. Dan has also studied the history of cardiac arrest and CPR, cardiopulmonary resuscitation, as well as our current practices of resuscitation. He published articles titled, later than sooner, a proposal for ending the stigma of premature do-not-resuscitate orders. That appeared in the Journal of the American Geriatric Society in 2011. Another article entitled, attending code status discussions at admission, which appeared in the Journal of General Medicine in 2011, and another article in hospital CPR in the New England Journal in 2009. Today, we're looking forward to Dr. Bronner's talk. The title, title you see behind me, Welcome to the Cardiac Arrest Paradigm. Please join me in giving a warm welcome to Dan Bronner. Okay, I want to welcome you to the cardiac arrest, it's still feeding back a little bit, cardiac arrest paradigm. You can still hear me? Question is, starting off with what is a paradigm? How am I using it here? It's hard to express in just one word, so I have a bunch of meanings, which all apply. It's a model, core concepts, which is sort of Coon's approach, a theory or a group of ideas about how something should be done, a way of looking at something, a typical example, a standard perspective, and a framework. So what is the cardiac arrest paradigm? I hope to flesh out this concept during this talk. One definition that I'm going to give you upfront is that it's the pervasive application of aggressive therapies based on narrowly defined parameters, frequently pertaining to a single organ system, whether or not they're expected to actually help the patient overall. And this happens disproportionately at the end of life in the paradigm. Cardiac arrest in CPR is the defining indication therapy combination of the paradigm. The paradigm came into existence coincident with the default application of CPR to everyone whose heart stopped in the 1960s. It then served as a model for the administration of other indication therapy combinations. I'm going to begin with an illustrative case in every person. It's an 88-year-old man who lives a fairly contented life in an assisted living facility because he has some mild cognitive impairment, which is very common at this age. He develops pneumonia, is hospitalized, and soon develops multi-organ system failure. He's then intubated for respiratory failure. He's put on dialysis for renal failure. He has a feeding tube inserted for failure to eat. Now, his family has consented at several points in the course of all these procedures. At those moments, they are given the choice to do everything or change their goals of care and become DNR. And they've decided to do everything with the hope that he'd get better. Now, this is a common scenario that plays out in hospitals across the country. And you can find patients like this in our hospital now as well as many in the city. It illustrates the onset of invasive organ-specific therapies applied in default fashion. The case also illustrates a method for negotiating care in the paradigm. This requires patients and families to opt out of usual care. What's important, though, is our case does not represent a singular failure occurring suddenly at the end of life. It's just more obvious. The paradigm becomes much more obvious in patients who are dying. Care under the paradigm equals doing everything, whether or not it will help the patient. And we as physicians move in and out of the paradigm in our practice. The question is, what is everything? Everything was actually initially defined as performing CPR. But this quickly expanded to a panoply of options, of indications and therapy combinations. CPR set a template for care and then acted, CPR set a standard for care and then acted as a template for other indication therapy combinations in the paradigm. How did it, a key to understanding the cardiac arrest paradigm comes from the question, why did a therapy such as CPR known to be ineffective in the vast majority of patients, especially those at the end of life, become the default for every patient whose heart stopped in the hospital? How did it happen? The usual explanation for this is that CPR needs to be administered in a fire drill like precision. And no one can think about it at that moment you need to apply it. But I think it's much more complicated than that. And there is actually a constellation of forces that work here. There's the momentum of the over 200 year history of resuscitation medicine and its evolving indications, which I will talk about. There's a nature of the treatment of death. There is a strong belief in the CPR project. There are strong economic and political forces that I will discuss as well. And also there's the way we the mechanisms that we developed in response to the default have become essential parts of the paradigm, the way the care is negotiated. cardiac arrest currently has three usages in modern modern day parlance. The first one is as a cause of death. And here we have an obituary from the New York Times happens to be of Claude Levy Strauss, who died at 100 piece of peacefully at home. And on this in the second paragraph, we see his son Laurent commenting that he died of cardiac arrest. Secondly, it marks a moment of reversibility between the last heartbeat and the finality of death, based on the potential of a therapy, making it a most contingent condition. In the first use, to say that cardiac arrest is a cause of death is not so much to ascribe it a lethal causality, but rather to affirm it is a moment endowed with the potential to restore life and thereby announcing a failure to do so. Highlighting again the contingent nature of this condition based on its potential therapy. The third usage marks a moment of struggle between the first two. Between those who wish to define the event of cardiac arrest as one of reversibility on the one hand, and those who wish to define it as one of finality on the other. In such cases, cardiac arrest becomes a point of contention, reflecting a battle of competing norms played out in ethics consults every day. I'm interested in the history of resuscitation medicine for the story it provides about its evolving indications. Looking at practitioners who were determining during this long history, who should get the therapy and under what circumstances? I'll start with the first systematic movement to treat drowning, which started in the 18th century. Move on to the surgical movement, which involved responding to a side effect of anesthesia in the 19th and 20th centuries. And then the important move out of the operating room, which started in the mid 20th century, onto the default in the late 60s, and then circumventing the default in the 70s and on to today. So here we see the cover of the transactions of the Royal U Main Society, which was started in London back in 1774, a few years after the Amsterdam society started. On the facing page, we see their report of 1775, in which they claim that in 33 out of 67 cases, life was successfully restored to drowning victims. And this was a very well, they kept really good track of who they were doing this to. There was a reward system that I'm not going to get into today. But it actually did work. These are from dioramas, pictures of dioramas from resuscitation techniques. They were actually in the museum of science and industry. This appeared later in the JAMA in an issue devoted to CPR. So you can see here some of these techniques were fairly aggressive. Others were more physiologic. We see a man being rolled over a barrel, which is where that expression comes from. We see one galloping on the back of a horse. And you can see, and here's a bellows, we can see that these techniques, some had some good physiologic basis. Part of what the Humane Society did was provide practitioners with equipment. Here we see a picture of the bellows, which is really the first mechanical respirator ventilator, because this was primary of ventilatory death. We also see a knife in which they performed tracheostomies. And so this is a fairly sophisticated way of resuscitating people at that time. And in fact, it did work. The important reason it did work was because instead of they changed, it was a misdiagnosis. These people were not dead. They were apparently dead. And so that gave them that moment then to reverse that situation. Here's just for pre-intresses, the tobacco resuscitator. So they, besides ventilating patients, they also gave them a heat was a big thing at the time, based on old ideas about the need for heat in the body. But also, they used chemicals and tobacco was one of the, a stimulant back then. And this is a bellows that were actually used at the time to provide patients drowning victims with, they would actually blow smoke up their rectums as part of the therapy. But what I'm really interested in is how the physicians of the time, the practitioners of the time, thought about their therapy. And this is a really interesting letter. It's a letter to Lord Cathgard, who was the president of what they called the Board of Police in Scotland. And he was trying to develop a Humane Society in Scotland. And he asked Dr. William Cullen, who was a well-known physician of the time, his Majesty's first physician at Ennenberg, to write a letter in support of the, of starting a, a Humane Society in Scotland. And the letter is, is interesting in that he describes the indications for resuscitation. Remember that a lot of the Fs are actually Ss in this. It must be acknowledged that there are cases in which from the destruction of the organization, and perhaps from other circumstances, the recovery of drowned persons may not be possible. But as it is seldom that such cases can be certainly distinguished, so they are very seldom to be supposed. And although the drowned person have lain for several hours in the water, attempt should be made for their recovery. Even supposing the case very doubtful, the labor of many fruitless attempts is not to be put in competition with one instance of success, where a person is recovered who must have certainly died if great pains had not been taken for his recovery. We see here sort of the indication creep that is sort of natural to a therapy like resuscitation based on the uncertainty of whether or not it will work and also the greatness of the reward bringing back someone to life. And this is a very current theme we see in the history of resuscitation medicine. The next big movement in resuscitation is in response to death from anesthesia. So in 1848, very quickly after they first started using chloroform, they saw that the chloroform could actually kill patients. These are approximately the incidents. The initial methods used to treat these victims was very similar and obviously inspired by the Humane Societies. And there are a few case reports in the literature, which I don't have time to go into, about using mouth to mouth ventilation and actually working at times just like they had used in the Humane Societies. But very early on they realized that this was not really mostly a ventilatory death. In some cases it was because of just too much chloroform, but some people actually had, even if you gave them the right amount of chloroform, they had reactions, cardiac reactions. And this is a quote from Dr. John Snow, famous from his work on cholera, who also was very interested in anesthesia and did a case series of people who had died from during surgery or being inducted by anesthesia. And he notes that in all cases in which the symptoms, in which the symptoms which occurred at the time of death reported, there is every reason to conclude, as shown above, that death took place by cardiac syncope or arrest of the action of the heart. And we see here an early reference to this notion of cardiac arrest. It hadn't been really, hadn't really come into the parlance yet. Now the concept of cardiac arrest has been discussed in various terms since Harvey described the motion of the heart and blood in his treaties, which you see here. Before cardiac arrest described, before cardiac arrest described all death, the term was used specifically to describe the stopping of heart that had two characteristics or terms that led up to the use of cardiac arrest. The first has to do with the suddenness of the event. So not everybody's whose heart stopped was developing sudden death or cardiac arrest. So first it's the suddenness. And what the suddenness really applies to is the, if you're expecting it or not. Obviously, there is no difference. I mean a heart's beating and then it stops beating. So it always stops suddenly, right? But the suddenness of it really has to do with if you're expecting it to stop. The second characteristic is the present presence of approximate cause. And dropsy at that time was described as one of the causes of cardiac arrest or a term like cardiac arrest. So in response to this new indication, this man, Maurice Schiff, working in the 1970s, he's a German experimental physiologist, developed a radical surgical technique for the new indication. And he was working on animals and the technique basically involved opening up their chest and squeezing their heart and pumping the blood. And he was able to use chloroform to create a state in which their hearts stopped, usually after they stopped breathing because he was giving them too much chloroform. But it also worked in patients who had primary cardiac could potentially work. And he was basically seeking a substantial remedy for paralysis of the circulation. Again, we don't see this term cardiac arrest, but paralysis of the circulation, which is referring to the same thing, occasioned by the use of chloroform, a fatality for which no reliable means of treatment have here to been found. So this is 1874. Hake is describing what Schiff is doing. Now the first attempt on a patient in response to to Morris's work occurred in 1880 by the surgeon Paul Nehons, who was doing an operation to remove a goiter. And his case is actually reported by his surgical assistant. And he he reports that he started doing artificial respiration. But after that didn't work. He resected the ribs, laid bare the heart and began rhythmic compressions. The patient didn't live and Nehons never reported the case. But once we had a successful surgical treatment in the 1900s, he retrospectively his his assistant said, we actually did this back in 1880. And he reported that in 1903. So that's the first case. By the turn of the century, there are actually several cases are reported successes. And this is a classic sort of style of how these papers are presented. This is by a man named W. W. Keane, William Keane. And he had one case which did not survive. But that didn't stop him from reporting about it. He what, and this is a very common practice at the time is he basically collected all the worldwide literature on cardiac arrest and resuscitated surgical resuscitation at the time and reported all those cases. And so this was it turned out that there were 28 cases and four of them were successful in this paper. And you can see the excitement and the how this this technique sort of captured people's imaginations. This is he presented the case, the Philadelphia County Medical Society. He presented that paper. And that was then reported in the Philadelphia Public Ledger and then picked up in the New York Times this month in 1904. And this is a quote from Keane, life apparently is extinct has been renewed or shall we say the dead themselves have been brought back to life. So this is was a technique that was practiced by I would say a very small band of sort of, you know, intrepid surgeons shall we call them. And the ones who actually report their cases, of course, you know, there are probably a lot of surgeons who are doing this without reporting. And it's impossible for us to know about that. But this here's a case by Norberry, who talks about cardiac massages, a means of resuscitation. And he's been interested in cardiac massage and he's his term for the indication here is apparent sudden death. And he talks about his cases here. But the thing that I'm interested here in sharing is how number eight how he talks about never give up on a case of apparent death under an anesthetic as hopeless until cardiac massage and its various accessories have been given a fair trial. So again, we see this notion of you have an indication, you get you should do it on everybody in who that indication applies. Here we see an early use of the term cardiac arrest in the case of a young man who had been shot probably during World War One, a soldier and who had chronic sinusitis who develops cardiac arrest and is actually brought back for a while. He doesn't survive but for a couple of days they bring him back. Here's another case in going into the 1940s here. Sometimes they did an abdominal approach as a young man who obviously was survive the case. And here they call it impending death under anesthesia. But we can see this is a graph I made of the reported cases of open cardiac massages. And we can see up until the 1940s it was a pretty at least the reported cases in the literature were pretty small. The 1945 report was a historical they reviewed all the world's literature and they had 143 cases that were done and that and they reported actually a 33% success rate. But this was going to change this change dramatically in the 1950s. And we see an increasing number of patients receiving open cardiac massage in the operating room. But the other really important thing that happens in the 50s is that they move the procedure out of the operating room. One of the reasons why the increased uptake of the procedure was the development of this device. This is Claude Beck's defibrillator that he built and as a picture I took of it in Cleveland at his archives. He uses I love the switch on it. Anyway, so he he defibrillate. He was the first person to actually successfully defibrillate a heart in 1947. He used these two spoons and it's internal defibrillation. So the chest is open and he's zapping it with those spoons. Those are the actual spoons. So Claude Beck who's defibrillated was is a really important character in the history of resuscitation. He developed this manual which was actually based on his course for open cardiac massage, which hundreds actually thousands of surgeons from all of the world came and took this course to learn how to do open cardiac massage. This first the first edition of this comes out in 54. And this is the second edition in 58. It says it's written by Hossler. But if you read if I've read this and it's all it's all it's all Beck's work. And this is in his previous recording his previous writing. This is Beck in the middle there. He's sort of the wide guy in the middle. And this is them. This is what surgeons would come and it was a weekend course and they basically part of the course was actually defibrillating a you know doing open cardiac massage on dogs. And everybody who took the course would learn how to do that. And it was a way of showing them that a work called back was also interested in getting the word out. He was a real advocate for this procedure. And this is from one of the movies he made which was titled the this is the choir of the dead in which he gathered all the people that he had resuscitated in the operating room and interviewed them about their deaths and their resurrections actually. The other important player in the 50s was you Stevenson who was actually a chief resident in surgery at the time at Bellevue Hospital in New York. And he this is reported the largest case series to date. And which is actually again a worldwide registry plus their experience at Bellevue. And he talks about it very openly about our definition of cardiac arrest as well as our indications for cardiac massage which is closely tied obviously may have widened. And the reason they've widened in part is because they develop what's probably the first mobile cardiac resuscitation unit which they use in the operating room. But they also use it on the wards. And basically he gives a course very much in the style of Beck in which he teaches the house staff at Bellevue how to do this procedure. And he lets them loose on the wards. And so they start doing open cardiac massage on people dying on the wards. It's really hard. Reading the paper it's really difficult to tell who they do it on and who they don't. What we get is really just the location. Because location, location, location is really the key here in terms of defining cardiac arrest because initially the only place you could have it was in the operating room. And so the important part here is that now in this series there are 13% are occurring outside the operating room. And you can see they're happening all over the hospital. So once you're out of the operating room the question is who do you do resuscitation on? You know which people who are dying. And it's not really discussed at all in the paper. But they do report a fairly good success rate which I'll get into. Another important thing that happens in the mid 50s well 1956 is another paper by Claude Beck reporting on the first man to have suffered cardiac arrest. It looks like from a heart attack or an MI who is successfully resuscitated. It's a case that he repeats over and over again in various places including his manual. This is a doctor who's in his mid 60s who's just leaving the hospital and has the big one just as he's walked outside the hospital and they grab him, bring him back in, crack his chest, defibrillate him and actually save his life. Interestingly Beck had advocated starting to do open cardiac massage outside the operating room in the late 30s in a paper. And he was pretty much alone in this. And he actually they talk about him doing this on the wards and performing open cardiac massage on the wards on people who are dying. But he never he doesn't report any cases until this one in 56. So that's like many years later. So theoretically he's probably they're doing a lot of these cases without much success. But Beck had a really interesting vision and this is a paper he wrote in 56 talking about the future of medicine. And you can see here there's a man on a golf course which is the classic you know CPR you know doing CPR on the golf course. But you can see here that he's not doing you know closed chest compression. This is his heart his hands are in this guy's chest and called back actually advocated that people lay people should be taught open cardiac massage very much like CPR is taught today. And that you should have the equipment you know easily accessible on the golf course etc. And that people could be saved because they had hearts that were too good to die was the way he termed it. Anyway later in the 50s we see Stevenson who's now moved to Missouri. His his his increases number of cases. He now has 1700 cases of of open cardiac massage and reports a 29 percent survival which is really good considering that all these people would have died if they had not had received the open cardiac massage. And most importantly I think he also reports 209 cases occurring outside the operating room. And he's reporting a survival rate in these patients of 21 percent which is also very good much higher than than than we get today. So so then this is actually my favorite paper from the the the whole surgical resuscitation movement and it's a paper that was already outmoded when it was published and so really did not get a lot of press because it's published it's a it's a it's the case reports on open cardiac massage but it's published two months after the first paper on closed chest compressions. So it was a little late coming to the party here and so not a lot of people read it. But what it is it's a very critical view of of open cardiac massage. So what they do this is Stahlgren and Engelcheck publishing in September of 1960. They they report on their cases of open cardiac massage in the operating room but also they report on their cases on the wards inspired probably by Beck and Stevenson. They say well we're going to try this as well. And so they do and they report their outcomes and they spend most of the time in the paper although they only do 25 cases on the wards. They spend most of the time on the paper talking about that experience because that's really the the essential experience for them. They have a very respectable you know almost 25 percent success rate in the operating room which means that they're you know they're doing the technique probably as well as you know was a standard of care then. But of the 25 people that they're resuscitated outside the operating room they only were able to bring back well as they say salvaged one. And this was a patient who was getting a bronchography. And bronchography is basically a procedure where they blow iodinated oil into your lungs to so they can sort of outline the bronchioles when they take an x-ray. And obviously this guy probably had a reaction to that and died. And suffered cardiac arrest and was brought back. And part of their critique which I think is really interesting and gets to one of the essential problems of the reporting on resuscitation is that when he looks at his cases plus he did a review he looked at the other cases in the literature at the time. He finds that a physician has usually performed the study which precipitates the arrest. In other words that these are iatrogenic or hospital cause deaths and that these are the people who are actually responding to resuscitation although that's never mentioned in any of the other papers on the subject. So this is the paper that sort of supersedes their paper. It's published two months earlier in July of 1960 and this is the first case of the first case series of closed chest compressions published by Kuhnhaven, Jude and Nicarbacher. And they talk about the triumph that you no longer need to do a thoracotomy which is really a big deal because a thoracotomy is really a messy and very sort of it's a very sort of bloody procedure and very obviously traumatic. So this is an amazing an amazing advance and the apocryphal story it could be true is so Kuhnhaven and Nicarbacher are both electrical engineers and the story is that Nicarbacher was working on creating a external defibrillator which had Paul Zoll in the 50s so that you didn't have to crack the chest to defibrillate. You could actually defibrillate from the surface and they had a Nicarbacher and Kuhnhaven, well Kuhnhaven had the grant from GE, General Electric, and because they wanted a portable defibrillator because so many of the linemen were dying from getting shocked at the time. The electricity was still, they hadn't really worked out a lot of the safety issues with it. And so Kuhn, Nicarbacher was who was his assistant, was working on creating the defibrillator and the story goes that they were experimenting on dogs and the dog was hooked up for with pressure monitors because they couldn't use an EKG machine because when you shock them the whole thing goes you know kablooey. So they had it they mounted to the heartbeat by looking at the changes in pressure and the story is he put the the the the lead, the defibrillator paddle on the on the dog's chest and when you put it on the chest he saw a blip in the pressure and he's and he started pushing and he saw that you could increase the pressure just by pushing down on the chest and that that was the beginning of closed chest compressions. Now what's really interesting about this case series is that they report a 70 percent success rate in their first 20 patients and this is a really it is never repeated and they only describe in detail in any detail five of the cases and in those five cases four are in the operating room which is the most common place where resuscitation takes place and one was a patient with the MI. One of the interesting things that comes out later in part I interviewed a Jude about this and also he has a paper about sort of his personal experience. Blalock who was the chief of surgery at the time was the mentor of this for this project although he didn't have his name on the paper and he one of the things he insisted on was that they have good data and good data mean that they have that they have tracings on the patients to make sure they really had cardiac arrest and so they were selecting for patients who were being monitored and the people who are being monitored are the people who are undergoing procedures so we see it turns out a bunch of people who are undergoing the cast which were just cardiac catheterization which had just become available in the late 50s and so a bunch of the patients who died had that and it turns out that just about all the patients except for that one guy who had the MI had atrogenic complications as the cause of their cardiac arrest but this was not mentioned at all in the paper and it's I don't think it's because they were hiding anything I think it's because that was the the style of the day in terms of not really going into a lot of details on who they're who they're doing the procedure on it's really a different sort of standard for clinical care so now all you need is two hands and you can do this cardiac massage and so they take their they they this is a second paper in which they expand the number of people they're doing resuscitation on to this is now a hundred 18 patients and you can see if you I broke it down here on this graph they're still having good success rate in the operating room and this is the operating of just surgeon cardiac surgeon surgery MI is always thought is a possible you know people have primary cardiac disease they thought they thought that that would be the the people who they would be most successful after the ones getting surgery and indeed they have a 13 percent success rate then the miscellaneous who they don't describe at all they have a 7 percent so it goes down substantially so in the second paper they they actually are very aware of this notion of what is cardiac arrest who are we doing this on and in the paper they they in which Jude is now the first author the surgeon this term once applied only to the sudden death associated with anesthesia and surgery they change it cardiac arrest is now the sudden and unexpected cessation from whatever cause of circulation producing cardiac activity so it's it opens it up so very early on though we see that there's some disenchantment with this procedure that the realization that CPR is ineffective in most cases is evident in 1962 I call that phase one phase two is the introduction of orders to sort of circumvent the therapy so this is a an interesting editorial that published in circulation authored by the American Heart Association the American National Red Cross and the Industrial Medical Association and at this time they have enough experience to know that quote most people who experience a sudden stoppage of the heart cardiac arrest cannot be saved even under ideal circumstances in a hospital and the next sentence actually gives a clue that cardiac massage is not yet become the default in the hospital because they say the least measure of success is in coronary heart attack cases and this is the group that they thought would have the most success as compared with those and you know after those in the operating room because the people with the least success obviously would be those who were you know in the terminal conditions that they talk about so they're probably not doing it on everybody interestingly and you know they know that it's not working on most people instead of trying to sort of limit the indications what they do is they propose limiting who can do the procedure and so they they say we believe that emphasis should be placed at this time on training physicians dentists nurses and specially qualified emergency rescue personnel so they want to keep it a professional they want to keep it in the profession because that's the way we control we can control too many people getting the procedure in appropriately so one of the things we another sort of that can be looked at as as a response to the poor outcomes of CPR in the wards is a development of actually the cardiac care unit and this is a paper by you day who developed the first cardiac care unit actually in Kansas City and he talked about their free the three phases of resuscitation program the first phase obviously is in the operating room the second phase is the management of cardiac arrest occurring unexpectedly on the floors of the hospital and so that gives you the idea that they're only doing it on people who who it happens unexpectedly not those who are expected to die but even in that in that case they have a very poor success rate he in this paper he talks about eight successfully resuscitating eight percent of the people and the reason he thinks that's going on is it's it's well known for the since you know early in the open cardiac massage movement it was well known that one of the biggest factors in predicting the success of resuscitation was the time between the cardiac arrest and the beginning of therapy and so decreasing that time by better monitoring was seen as one way of improving the outcomes the other thing is being able to train nurses specifically to do cardiac resuscitation in you know very quickly and so they created the first cardiac care unit specifically to treat cardiac arrest in 1962 and this took on this became the standard of care very quickly most hospitals developed it became you know standard to have a cardiac care unit starting in the early 1960s after a few years though people realize that this wasn't that helpful either that even in the cardiac care unit cardiac arrest was not treated very effectively and this is a paper by Bernard Lown who set up a similar cardiac care unit at Beth Israel hospital and he talks about the focus of management in the cardiac care unit should be altered from resuscitation to the prevention of the need for resuscitation and so we see here a change in focus at the same time this is a paper by sister Mary Fields comes out in 1966 and she describes the CPR team in a medium-sized hospital actually in Fargo North Dakota and we see here sister Mary Fields intubating a patient she was a respiratory therapist and she's very excited about this this procedure and she just talks about it as a right it's a right of patients even in small hospitals in the middle of you know North Dakota should patients have the right to this procedure and so this is sort of another movement and other force in the increasing application here we see another editorial are very much very similar to the one in sixty two and the last line here actually this is it's an editorial but it's also it's the guidelines for doing CPR which is where a lot of these editorials come from CPR is not indicated in a patient who is known to be in the terminal stages of an incurable condition so we see here a very clear articulation that you shouldn't be doing it to everybody at the same time there's no mechanism proposed for how to do this and so what was actually happening in the hospitals in the 1960s is really it's hard to know because there's hardly any literature any medical literature about how people were dying in the hospital at this time one one piece of evidence that I was able to find is this letter which appears in the British Medical Journal and it's actually written by a British English pathologist this guy William St. Clair Simmers who's the head of pathology at Shearing Cross Hospital and he describes the case in this letter he describes the case of his story of a doctor age 68 who's found to have widely metastatic gastric cancer it's gone to his liver and and as well as his spine and he actually asks it's a really sad case he asked that no further treatment be given he says I'm you know I'm in horrible horrible pain despite pain medicine just don't do anything more to me this is after actually they do an embolectomy on the ward when he has a pulmonary embolism and he actually writes this in the medical record and despite this request you know in this letter which apparently several doctors who were there told Simmers about this he continues to re-CPR on several occasion even at one point he's noted to be de-cerebrate basically brain dead but that hasn't occurred you know that's hasn't been created as in condition yet and even after that they do a tracheostomy and they're planning to put him on a ventilator but then his heart finally stops and he's allowed you can say allowed to die and so you know this gives you a sort of a picture of what was going on in the sixties as CPR was becoming the default but there was yet no mechanism for not doing it so one of the mechanisms actually for not doing it in some patients comes out of this paper is in 1968 the same year few months later by the ad hoc committee at Harvard who finally defined brain death and this is you know partly most you know obviously a response to people who can have their hearts continually to be restarted who actually whose brains are totally gone and so this we can stop doing CPR now if you have brain death so that's one one way to not do the therapy so another factor in the formation of the cardiac arrest paradigm that's really underappreciated I think was the perfect storm of the infusion of billions of government dollars into medicine starting in 1966 with Medicare this is happens coincidentally with the broadening indications for CPR and perhaps the final force for the universal default application of CPR and the CPR project was the money to pay for it and the way that this was worked out was really ingenious was done by the American Medical Association who created this current procedural terminology the first edition comes out in 1966 coincident with the starting of the funding and in this in this manual they basically list all the billable procedures and their indications that so that doctors can now bill Medicare the government and when it first came out is very thin book mostly surgical procedures but it increased by seventy percent for the second edition and there were very few medical procedures actually at the time that were billable but we can see here that cardiac resuscitation for cardiac arrest becomes a billable billable procedure in 1970 so CPT with the current procedural terminology is an important part of the paradigm it fuels it by specifying what is a billable procedure and creating the mechanism for collecting fees for that one of the things that it did as well was it created a new important agenda item for physicians and it's really evolved into an obsession with documenting for billing that we live with now and that they specified the requirements what needs to be reported what information needs to be reported to justify the charges and so this became a very important part of physicians jobs in the paradigm and interestingly patients were rewarded for physicians are rewarded for patients being sicker and so there is a lot of energy placed in into documenting just how very sick the patients are so 1974 sees the there's a large supplement I showed you the cover before with all those old dioramas this is a big supplement that comes out of JAMA describing the latest techniques for CPR but in it we find a paragraph again another paragraph talking about that it's not indicated in certain situations such as cases of terminal irreversible in illness where death is not unexpected or and so this this notion again it's very similar to the 1966 editorial that it doesn't work in these people and it's not indicated but finally we have a mechanism and so when CPR is considered to be contraindicated for hospital patients is appropriate to indicate this in the patient's progress notes it's also appropriate to indicate this on the physician's order sheet for the benefit of nurses and this is really key because nurses are the ones who are who are diagnosing cardiac arrest on the wards and they're the ones who are initiating CPR and so we see that the first DNR order is really a communicative act between doctors telling nurses don't do this and the other interesting part of this is there's actually no mention of patients being involved in the decision in 74 so you know DNR was only one of the of the mechanisms that people came up with for dealing with this default but other other mechanisms that didn't become popular but I think a very important historically were also proposed and this this is an attempt to navigate care once the defaults in place that was put into place in the ICU at Mount Sinai Hospital in New York City and what it is is a prognostic classification system and what they want to do is help define overall therapeutic goals and critically ill patients and it's I think it's really interesting here this that they need to explicitly articulate overall therapeutic goals because of their conspicuous absence in the onslaught of life-saving default therapies and the next line is also interesting it's to force the conscious decision as to use or a mission of heroic measures including CPR and so here we're talking I mean what they're saying is we're not making conscious decisions about how to treat our patients we're doing this this thing where we where we treat them we're treating everybody in the same way in the same year 74 this is a very important case in this history we see Karen Ann Quinlan ODs on alcohol pills and she received CPR from her friends here and it's not it obviously doesn't work that well she's becomes vegetative and her family requests her to be taken off the ventilator but they won't do it and so they take it to the courts and the Supreme Court in New Jersey finally supports the removal of life support from from Karen in 76 and this is an amazing amazing event that happens I think that that's not only because it's the first time that it's publicly sanctioned but also it opens up the discourse about what's actually happening in hospitals and we see this editorial in the New England Journal that comes out a few months later terminating life support out of the closet in which they the hospitals finally come clean with what's actually going on in the hospital and so and this is a paper this is along with this what they report what's happening in mass general which is actually doing a very similar system to tag in the ICU but also the other paper that's probably even more important is by Rapkin in which he reports in which he proposes that patients be the ones who decide whether or not they should be DNR which was obviously a very big change in how this occurred and this was slowly became the standard so we see that the these sort of prognostic classifications don't really catch on that well but what does catch on is this whole DNR order and and that becomes sort of a surrogate for the classification system and so what we see here is a as an early paper written about DNR in the early 80s 1982 and he talks about instead of that because it had not become that popular DNR was still was not you know it was a pretty uncommon order at the time and his his proposal is that instead of making it a negative order like doing do this don't do resuscitation they change it to a positive order do comfort measures only and what we see here is that DNR is used as a drastic it's used to a drastic change in what care should look like and it the meaning is now instead of doing everything we provide comfort now this whole notion of using DNR in that way is further repeated the next year by Lowe and Steinbrook he says physicians have no obligations to provide futile useless treatment DNR is appropriate when further treatment is futile so that successful CPR would only prolong the process of dying so DNR is appropriate at the moment when all other treatments are futile but interestingly in the same paper Lowe and Steinbrook say but a DNR order means only that CPR will not be performed which I think really shows there's sort of lack of appreciation of a meaning of what a meaning of DNR is even in the in the very paper that they're presenting at the time and this confusion would continue and this is in the 80s people started realizing that less aggressive care that DNR really was signaling not only for going CPR but also set an agenda for for less aggressive care and there's a paper here by the group here at the McLean Center in 88 and this is Brody and Tomlinson talk about it makes a big difference what's the motivating rationale for DNR what what it's actually means or what what the people who are proposing it mean and so this is a obviously the cause of a lot of confusion that we still have today surrounding especially as DNR becomes people advocate doing it earlier and earlier so the the cardiac risk paradigm profoundly altered the doctor-patient relationship with sacrifices on both sides patient relinquished their control of their bodies for the potential of extended life and physicians gave up their judgment about what was best for a particular patient at the moment of cardiac arrest when the choice was finally given to patients it became the an important moment of patient autonomy as defined in the paradigm in in essence in essence what what it is is a consent to participate or stay in the cardiac arrest experiment which is to say the cardiac arrest for everyone whose heart stopped was a large scale experiment physicians when they make attempts to keep patients in or out of the experiment but mostly because of the default the physicians are very motivated to get patients out of it motivated by the knowledge that it would not help when when physicians do that in this system they're they're seen as being paternalistic in part because defining the way we define cardiac arrest as I talked about in beginning is not really about efficacy but really about expectations so another aspect of the doctor-patient relationship that was profoundly altered by this was the claim inherent in in the default application of CPR is the claim that we really have a life-saving therapy and this really created a new responsibility for the life of the patient that I think doctors took on in the 60s and 70s and continues today and I don't think it's a coincidence that we see when with the failure to meet this claim we see the birth of the medical malpractice industry during this time with claims increasing drastically from the 50s to the 80s ten times the tenfold increase so I try to give you sort of a whirlwind introduction to the paradigm and the question that is how do we move beyond this paradigm I think for the first step really is appreciating when we're in it what would it what how it's informing care today and I think one of the what one of the ways to to work to get beyond it is more truthful telling of the limits of medicine in the 21st century you know even though most hospitals are among the top 100s all of the country if you see their signage you know I think we need to get a level of truth-telling that we really have have not been doing up until now so I think you know when doctors talking to patients they got they need to present real therapeutic options not everything that possibly indicated or billable and I think this is one way of regaining trust which in very in in a lot of ways was lost in the paradigm I think what we need is a more careful telling of what is happening in the present and less about sort of advanced directives which people are obsessing about so care in the present which de-emphasizes code status I think you know people are obsessed with you know whether or not we're going to do resuscitation then your life it's it's obviously not a big issue because the therapy doesn't work that great unless you have something iatrogenic and you're not going to know if some that's going to happen unless it happens though it's fine for people not to want it I'm not pushing resuscitation on everyone I'm just saying I don't want to be dnr so we need to de-emphasize code status you know people need to pick a surrogate for when they can't make decisions that's not such a big deal and as we make it I think the reason it's a big deal now is we tie it to code status once we separate that I don't think it'll be a big deal and I think of the other part is you know Pellegrino Edward Pellegrino a Dancel Macy's mentor talked about virtues though the way I see them happening going back to apocrates here is a notion of you know as physicians what are our goals really we on to alleviate suffering we want to reduce the severity of illness and we want to recognize treatable from untreatable diseases and you know to bring this to the 21st century we need to do that and tell patients this is what we can do and this is what you know we we can't treat and to be honest about that and if we follow these goals I think you know that would radically alter the practice of medicine today thank you mark had to leave for Mexico so questions Dan you showed in 1962 article I think in which there was the recommendation that resources for CPR training be devoted to physicians and nurses and you characterize that as trying to keep control and make it professional but the the wording that was there which which fits more with my impression is there was a matter of where do you devote the initial resources for training you've got like two million people between doctors and nurses who were essentially untrained at that point and who would need to be trained in this procedure and that's a substantial challenge no if you devote if you devote resources to them first yeah seems to only make sense now this was not a resource issue this is who who should be allowed to perform the procedure so this was a thing that the seat the red cross had a bunch of people who who were waiting to be lay people who who willing to throw big bucks into this and the question is who should be allowed to do the procedure and this was a clear move to make it a medical procedure and not a procedure for lay people let me go bag it's fine but and so in the 66 editorial that I showed they reverse that and they said now it's you know we're going to train lay people as well it's they change it from a medical procedure to an emergency procedure and so that they were able to start training lay people as well because it was a tremendous groundswell people really wanted to learn how to do this and this was I see this not as a matter of you know limited resources but as a matter of control of who should who should get to perform CPR thanks down that was a most amazing tour to the development of everything up to now and I just a couple of comments and then just a question can you put a couple of comments and then a question of your opinion I'm I'm struck with how there's a such a direct parallel now in the diet in the discussion about who is allowed to perform the procedure only now the procedure is the conversation the conversation yes and there's that same argument over whether that conversation should be restricted to the doctors and the nurses versus whether it should be expanded who can be taught who's qualified my question to you is I hope this isn't all that rhetorical but what are the elements in the telling of the story of what's happening now how long would that typically take for somebody who has a chronic progressive ultimately fatal but right now stable condition and and if it's a lot if that conversation takes a long time who's going to do it and who's going to pay for it well I think we could have this conversation once you know put it on television you know this is this is the truth about this procedure you don't need to have it individually with people you know not getting resuscitation at the end and I mean you're talking about the goals of care conversation which conversation you're talking about maybe I misunderstood what you're saying yeah to me that what's happening now has to do with you know you are that's no that's how no that's how a doctor should be interacting with their patients all the time I mean this is this is what's going on right now this is what we're going to do about that that's doctor patient interaction it's not about you know it's not about all this other stuff I think that the whole notion of the goals of care conversation and and and sort of creating that as a billable as a billable procedure I think is really ironic in the face of the paradigm you know they got CPR to be billable and now they say well it doesn't work so we're going to create a conversation now so you don't have to do it I think doing it is ridiculous you know when it's obviously not going to work and I think physicians need to take a stand and say I'm not doing it you know it's not I'm not doing this thing you know it's it's a matter of you know and so then you wouldn't have to get people to sign this thing and say I'm giving up you know all this stuff because I want to be DNR you know I think DNR creates and the whole notion of the goals of care which you know the language going back to the 1974 really shows that it was it was a bomb for the you know a SAV for this default application of therapies what I'm talking about is not doing any therapies default I'm talking about doing therapies that are indicated at a given moment not because there are a list of things that tells us what to do now and that's you know that's a radical notion I understand that but you know the goals of care conversation I think is you know when when patient it's it's that's not that's such a well in language you know what we mean by the goals of care conversation we're still trying to make it like a choice for patients what are your goals of care here what we're really telling the patient is we got nothing left that's going to make you better but we can make you comfortable which is a fine thing but it has nothing to do with the goals of care it has to do with you know we got nothing left and we can make you comfortable there's no choice involved we can you know beat the heck out of you to if you want that and we'll do that in the paradigm I won't but a lot of physicians will yeah Dan could you expand on that a little bit I think we know where you stand on it it was fairly clear do you think that part of the conversation that doesn't does or does not happen ought to begin with the telling of the tale to patients and family that you're dying and just say that for that purpose now you're saying you're saying that you know you're emptying it but I think that there is a part of our conversation that we have with patients over time that has prevented us from saying things like that well and I think that if we start that conversation by saying you're actually dying there is no more to do that I think that conversation can be very short well yeah I mean that's a short conversation but the thing of it is is that you know in some ways we're all dying right it's just a matter of time right I think that the really big push for forgetting telling people that they were dying was that we don't want to do resuscitation on you when you die that was one of the big impotences for those conversations because we're gonna have to beat the heck out of you if you die in the hospital without this order and so that that was a very compelling reason to make sure people knew that you know and I think people need to know that you know given an idea of their prognosis I am all for that you know to the extent we can do that we know we're not that great at doing it I think what's important is the people to know what we can offer them and what we can't you know that's what's important you know what therapies we have not the exact time you're gonna die you know and and I think telling people you know they're gonna die you know it's obvious I'm gonna die you know and you know I think you know after a while it's really obvious not such a great service we're doing by time it's a great service when we free them from the the brutality of the things we're gonna do to them but that brutality shouldn't be happening in the first place right and so we've created this system in which we need to do all this stuff to circumvent these defaults that we put into place because of those forces yeah so what from my experience as a resident of my internal medicine resident right now what how many minutes you've been practicing go ahead I'm sorry I'm just kidding you know it seems like the reason it's a default is a practical one what's the practical reason iatrogenesis is one of the few times that we can actually get someone back with CPR as you write out iatrogenic things happen unexpectedly all the time in the hospital and expectedly and we know when we do something iatrogenically right you know and if something is unexpected the only reason that the person would get CPR in that scenario is if it was the default so I guess from that very practical level you have a response to right so if you're in a situation where a patient has had an iatrogenic complication and they go into cardiac arrest unless you know they if people knew that they were going to resuscitate resuscitated because we thought it could actually help them you know at those moments then they wouldn't want to be DNR or some people would and some people would still want to not get resuscitation and those people should not get it you know that's fine but it's the people who are still into the medical you know they're pushing to get better or to at least to get better to at least somewhat better they're still into that then they would be open to be get CPR if we knew that we could have some chance of reversing it i.e. that it was an iatrogenic event and so being open to that I think is fine doesn't mean we have to do it and people are obviously dying and at the moment you see someone's dying you can see it's not iatrogenic anymore this person is dying here you know we don't need to do CPR now right you know when that happens right that's when you try so hard to get your DNR order yeah a gazillion yeah it really depends who they do it on you know if if if they do it on people that the really iatrogenic complications you know if we give you too much potassium and you go into v fib you know we can bring you back with you know 95% success rate right but if you're you know at the end of a terminal illness from metastatic cancer the the rate is zero so it's there's a big variation that's part of the problem with it yes thank you an internal yeah yeah yeah i think that the the fear of of legal ramifications i think is is one of the that's a great quit the fear of legal ram the ramifications of not doing CPR i think are one of the reasons that that keep it going the way it is what was it doing it's opening yeah i actually had a slide you know i have way too many slides i didn't talk about a lot of things that i could have because this is work that i've been doing for a long time but here we see this is by a lawyer in 1968 and he's talking about he's talking about the notion of setting a setting standards of care so with these theoretical distinction of mind we may turn to analysis of specific aspects of medical decision not to be a long life the first problem is to isolate the relevant the relevant medical activity the recurrent pattern includes stopping cardiac resuscitation oh this is actually not the slide i want whoops whoops oh sorry anyway so in it later on this paper Fletcher says we you doctors have a chance now to set standards and set expectations for patients of what they should expect in the hospital and this is 68 before the default and he said you shouldn't let the courts decide this you guys should do this you should set the standards of when you're going to apply the therapy or not and obviously doctors didn't do that they they left it they so i see it sort of an a little bit of an abdication nobody step forward say these are the this is where we're going to do CPR this is where we're not going to do CPR and if they had set those standards of care then i think they were the created the expectations you know he talks about creating expectations of patients when they're going to receive it what what happened was because it became the default everybody expected to get it and everybody expected to live forever because you have the cure for death and i think you know physicians you know i think they they really benefited substantially from that claim you know not i don't think doctors were doing CPR because they were getting you know billing for it but i think that there were moves to to make CPR the default by administrators and people who are into the business of medicine that said this is a really lucrative thing we should be doing this a lot and you know and i think that's part of this whole paradigm and the fact that met the you know all this money came into the the the met medicine at that time is another impetus for the whole malpractice you know industry that exists now yes there ever been mal practice charges for inappropriate CPR inappropriate you mean if people had DNRs and had CPR or that or a little more broadly people who shouldn't have gotten CPR even if they weren't technically DNR who would bring if they were not DNR no that's a standard of care it's a do CPR you can't get sued for that yeah all right what if they would DNR there are cases where people sued and I think successfully sued because they were still alive because they got resuscitated yeah you see the external developer ladders and airports and on trains and all over the place are they effective or they does it make sense to expand resources on such things that's a great question you know I think the the I'm not an expert on those I think the word is still out I think the possibility is there that if you do have you know there are people who have purely electrical deaths and it doesn't happen very often but if it does have you know an airport is where a lot of people walk through a high stress environment it's possible if you have an electric death if you get the fibrillator right away that you could survive so I think the potential is there I don't think it's hurting anybody the way all this other stuff is so I'm fine with those even though I don't I don't think they've been that successful yet yeah all right thank you