1. Make Your Wishes Known The Realities of Advanced Medical Interventions
Micki Jackson , coordinator
Approximately 90 minutes with time for ?’s later-
Handouts : WAHA, list of medical terms used

2. Koala and Cathy – ICU RNs

4. Advanced Medical Interventions
CPR- Cardipulmonary Resuscitation
Mechanical Ventilation- Respirator (breathing support)
Pressors-Intravenous drugs to support blood pressure
Artificial Nutrition- feeding tubes
Dialysis-kidney function

5. Reality Check- Life is 100% Fatal
In the US 540,000 people experience cardiac arrest each year-most out of hospital- Circulation 2013
Age range- birth to 100+ years
5-15% survive to hospital discharge
What do these survivors have in common and how are they very different?
Our survival rates have improved- EMS,CPR, medications, devices

6. Cardiac Arrest in Hospital-better #’s?
200,000 in-hospital cardiac arrests -American Heart Assoc
18.3 % survive to discharge
No improvements since BUT……
Percentage discharged to home is less
Discharges to hospice (17x) and long term care facilities (6x) increased

7. Advanced Life Support Examined
CPR- cardiopulmonary resuscitation
“The heart is compressed to a depth of 2 inches by squeezing it between the rib cage and the spine”
Blood is squeezed out of the heart and pumped to the brain and other organs
Who gets CPR?
Who gets good CPR
AED’s-automatic external defibrillator- not all heart rhythms are “shockable”

8. Effective CPR

9. CPR

10. Lucas Device

11. CPR aftermath

12. Elderly (65+) CPR Survivors- JAMA Internal Medicine 2013

13. Survivors: Functional scoring-
Cerebral Performance Categories

14. Age Matters….
Age
% of survivors with good neuro -logical function or minimal deficits on discharge (could be CPC1 or 2)
<70
12.6%
70-74
10.2 %
75-79
8.6%
80-84
7.6%
>-85
4.5%

15. CPR Works but age matters

16. History matters… Reason for hospital admit
% survival to discharge with “better” outcome (CPC 1)
Major trauma- broken bones 6%
Acute stroke- bleed or clot
3.7%
Cancer-tumors
5.2%
Blood infection-sepsis
3.6%
Liver function poor
4.4%
Admitted from a skilled nursing facility
3.2%
Kidney function poor
6.4%
Pneumonia

17. Mechanical Ventilation advanced airway/breathing support

18. Ventilator suctioning

19. Tracheostomy- temporary or permanent?

20. Pressors- Blood pressure support adrenaline- fight or flight
Medicines given intravenously

21. Kidney injury- dialysis

22. Nutritional support

23. Perception is everything…
Your doctor
Your nurse
Your family

24. Really Advanced Medical Interventions

25. Patient Scenarios Examined
Joan Rivers 81 yrs old Routine upper GI scope exam because she had voice changes and indigestion She stopped breathing during sedation for the procedure and suffered brain damage from lack of oxygen Quote from the ME…… “resulted from a predictable complication of medical therapy” ALL elective and emergent procedures have predictable complications- do you understand the real risk?

26. Elderly man in Florida

27. Life after Survival
Where will you live? New medicines and treatments Communication and memory Who will take care of your daily needs Who is left at home if you can’t be there It’s expensive and who pays- do you have LTC insurance? What will your Medicare cover? What about Medicaid?

28. What if I don’t want “Everything”
Deciding not to have CPR (“DNR” means do not resuscitate) does NOT mean no care- patients may still want life support treatments in a hospital or ICU.
Antibiotics, IV fluids and other medical treatments are available
Nurses help patients stay comfortable- you get the care you need and WANT

29. “Doctors have a hard time with this”

30. Other Choices
Palliative Care- a team that focuses on providing specialized care to relieve the symptoms, pain and stress of serious illness.
Hospice -support in the community
Comfort Care- final hours/days in hospital

31. Your Life- Your Choices

33. WAHA website- downloadable documents

35. Time for Questions….. ?

36. do things need to change?--Editorial in Journal of Palliative Medicine
“We need to stop treating CPR as something special -ie a default action; as something that is a genuine medical option even when it’s therapeutic potential is remote”
“It’s the only thing in medicine that we treat this way, like it’s a sort of human right, as opposed to a complicated medical procedural intervention with indications and contraindication, good reasons to do it, and good reasons not to….”
“Hospital QI compartments must start looking at questions of whether there was an indication for CPR in the first place and if not—why was it offered/why didn’t the patient have a DNR order/why weren’t people discussing this with the patient/family?”