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The first time I saw a patient who had received CPR, the experience wasn’t what I expected.

Sure, I thought she wouldn’t look well. After all, her heart had just stopped beating. But I wasn’t prepared for the scene before me: a frail woman in her mid-80s, barely conscious, vomiting, with broken ribs and a bruised lung. Her stomach was bloated and her chest was bleeding. She looked more like a survivor of CPR than of cardiac arrest, I thought to myself. When she died a few days later, I couldn’t help wondering if she really knew what she was getting herself into.

At most hospitals, it’s routine to ask patients about their resuscitation preferences when they’re admitted, regardless of how healthy they are. “In the event your heart stops beating…” and “If you are unable to breathe on your own…” are commonly used (though probably not the most helpful) phrases introducing these discussions.

In conversations I’ve had with patients, I’ve encountered a variety of responses. One patient — young and relatively healthy — became tearful, assuming that I was asking because of his imminent demise. Some have avoided the discussion because they didn’t think it was likely or, maybe, didn’t want to think it was likely. Most have thoughtfully grappled with the issue. But consistently, most of the patients I talk to don’t understand what exactly CPR is, what it’s for, and what its risks and benefits are.

The origins of cardiopulmonary resuscitation date back centuries. The 16th-century physician Andreas Vesalius wrote, “But that life may…be restored to the animal, an opening must be attempted in the trunk of the trachea…you will then blow into this, so that the lung may rise.” Two centuries later, the Scottish surgeon William Tossach described performing mouth-to-mouth resuscitation on a coal miner: “I applied my mouth close to his, and blowed my breath as strong as I could.”

But it wasn’t until the 1960s that CPR in its current form was introduced into American medicine, initially as a treatment for sudden cardiac arrest after heart attacks, drowning, drug overdoses and other potentially reversible conditions. By 1974, it was so widely used that the American Medical Association issued a recommendation that patients’ preferences be documented in their medical records. Since then, the use of CPR has continued to grow, and millions of people around the globe have been trained to perform it.

Experts say CPR is a lifesaver, and with good reason. Each year, more than 350,000 people in the United States — one every 90 seconds — experience cardiac arrest. The vast majority of these do not occur at a hospital, and those who receive CPR from a bystander are up to three times more likely to survive than someone who doesn’t receive such assistance.

But CPR is not without its drawbacks, especially for patients with chronic conditions and terminal illnesses. Patients who receive CPR may sustain not only a number of immediate complications like rib fractures, damaged airways and internal bleeding, but also serious long-term consequences like brain damage resulting from extended oxygen deprivation. Some argue that in patients with very low likelihood of returning to a reasonable quality of life, CPR leads to an unnecessarily prolonged and painful death.

Precise survival rates after receiving CPR are tough to come by and vary according to patients’ underlying health status. Research generally suggests that about 40 percent of patients who receive CPR after experiencing cardiac arrest in a hospital survive immediately after being resuscitated, and only 10 to 20 percent survive long enough to be discharged. Research also suggests that patients significantly overestimate the likelihood of success. A recent study of older patients found that 81 percent believe their chances of leaving the hospital after CPR are greater than 50 percent, and almost a quarter believe their chances are higher than 90 percent. This discrepancy is important because patients’ preferences for CPR are strongly related to their perception of how likely it is to be successful: Older adult patients are half as likely to want CPR near the end of life when they are told the true probability of survival.

Some have suggested that misrepresentations of CPR on television may lead patients to have unrealistic expectations of what the procedure entails and the likelihood of success. Survival rates for patients receiving CPR on popular, prime-time medical TV shows have traditionally been much higher than in the real world. One study found that 75 percent of TV patients who receive CPR are alive immediately after, and 67 percent of patients survive in the long term. Other research has shown that though recent shows like “Grey’s Anatomy” have more accurate immediate survival rates, they are still misleading. TV portrayals of CPR are mostly binary—full recovery or death—with little attention given to survival to discharge or long-term disability. TV patients also tend to be younger and experience cardiac arrests because of trauma, unlike real-world CPR recipients, who tend to be older and have longstanding heart and lung disease.

It’s not unreasonable to think that news media representations of CPR are shaping patients’ views of the procedure. Many older adult patients report TV as a primary source of health care information, and a study of adolescents found that those who watched more medical dramas have significantly higher estimates of CPR survival rates. Other work suggests that almost all people have unrealistic expectations of CPR, but those who use TV as a source of information have the highest survival estimates.

None of this means that CPR isn’t effective in many situations or that it should be performed less frequently. But it does mean that there’s a lot to clarify. CPR is one of the few treatments that patients must expressly opt out of instead of opting in to and as such carries a special burden of explanation. Preserving patients’ autonomy and assuring their true desires are reflected require that they have an accurate understanding of CPR. In the end, we are all potentially providers and recipients of CPR, and we should know what we’re getting in to.



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Dhruv Khullar, MD, MPP is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.