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Reassessing Cardiopulmonary Resuscitation in Hospitalized Patients With Coronavirus Disease 2019*

Sprung, Charles L. MD

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doi: 10.1097/CCM.0000000000004962
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  • COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has caused morbidity, mortality, and an economic crisis worldwide. Necessity has required adjustments in the provision of medical care including, for the first-time in developed countries, triaging of scarce resources and considerable increased use of telemedicine as examples. Changes in procedures due to the pandemic offer an opportunity to reevaluate policies that may not be the most medically beneficial or efficient even under normal circumstances. Although cardiopulmonary resuscitation (CPR) was developed for sudden cardiac arrhythmias leading to cardiac arrest (patients too healthy to die rather than those too sick to keep living [1]), CPR is typically performed on most dying hospitalized patients who do not have a “do-not-resuscitate” order.

In this issue of Critical Care Medicine, Lim et al (2) report a meta-analysis of the incidence and outcomes of in-hospital cardiac arrests (IHCA) in patients with COVID-19. This review affords me the opportunity to address the issue of CPR in hospitalized patients in general and specifically in COVID-19 patients during the pandemic at a time of scarce resources. As the mortality of IHCA in COVID-19 patients is exceptionally high and carries risks to healthcare workers at a time when ICU beds are limited, some have suggested that COVID-19 patients should have universal do-not-resuscitate orders (3). A brief summary of the incidence, characteristics, and outcomes of IHCA patients before and during the present COVID-19 pandemic from several reviews provides data to help answer this question (Table 1). Before the pandemic, IHCA survivals had been increasing over time (4,6) with a parallel decrease in neurologic disability (6). IHCA mortality, however, was 98% for patients with moderate or greater frailty (7). Hospital mortality of IHCA in COVID-19 patients during the pandemic was higher than for IHCAs pre pandemic with worse neurologic outcomes (2). This may be related to the higher number of respiratory causes of cardiac arrests and nonshockable rhythms in the COVID-19 patients. Higher mortalities were found in patients with increased age and nonshockable rhythms before and during the present pandemic (2,4). During the pandemic, hospital mortality after IHCA was higher in non-ICU locations than in the ICU (2), whereas before the pandemic (2003–2010), mortality was highest in an unmonitored ward setting (89.4%), followed by the ICU (86%) and lowest in a monitored ward (80.7%) (8). The proportion of patients surviving IHCA prepandemic improved over time with greater survivals in the inpatient ward than the ICU setting (8).

TABLE 1. - In-Hospital Cardiac Arrests Before and During the Coronavirus Disease 2019 Pandemic
Period COVID (Lim et al [1]) Pre COVID (Andersen et al [4]) Pre COVID (Armstrong et al [5])
Patients Hospitalized COVID Hospitalized ICU only
Age (yr) Mean, 63.7 Mean, 66 54–68.8
Cause, % Respiratory: 87.5 Cardiac: 50–60 Cardiac: 24.4–78.5
Respiratory: 15–40 Respiratory: 13.3–39.7
Rhythm, % Nonshockable: 84 Nonshockable: 81 Nonshockable: 76.8
Asystole: 36.4
Pulseless electrical activity: 47.6
Frequency 8.0–11.4% ICU patients 9–10 per 1,000 admissions 22.7 per 1,000 admissions
1.5–5.8% all hospitalized patients
Location, n (%) ICU: n = 584 (68.9) Half in wards, remaining half ICUs, operating rooms ICU: n = 12,824 (100)
Wards: n = 209 (35.8)
Unspecified: n = 54 (6.3)
Hospital mortality, % 91.7 75 83
Range: 44–100
ICU patients: 88.7
Non-ICU patients: 98.1
Neurologic disability CPC: 1–1: 7% CPC 1–2: 85% CPC: 1: 20–68%
CPC: 1–2: 9%a CPC: 1–2: 82–83%
CPC: 2: 19–50%b
COVID = coronavirus disease, CPC = Cerebral Performance Category.
aThree studies.
bSix studies.
CPC score of 1 (mild or no neurologic disability); CPC score of 2 (moderate neurologic disability) (2).

If the mortality of IHCA in COVID-19 patients is greater than 90%, is CPR in these patients futile? CPR in these patients would not be futile based upon the proposal by Schneiderman et al (9) for futility—when medical treatment has been useless for the last 100 cases, a treatment that merely preserves permanent unconsciousness or cannot end dependence on ICU care. In contrast, it would be futile by the suggestions by Prendergast (10)—physicians being compelled to proceed with intensive care for marginal benefits. But doctors already admit patients to ICUs with prognoses worse than 92% mortalities. In developing a consensus for triaging ICU beds, agreement could not be reached for the benefit necessary to justify ICU admission; only 48% of respondents agreed to a survival chance less than or equal to 1% (11). Therefore, despite a very high mortality for IHCA in COVID-19 patients, it does not appear to be so high as to justify a blanket denial for CPR and ICU admission.

Perhaps, the combination of high mortality together with the risk of infecting the staff during CPR and the scarcity of ICU beds should determine whether to perform CPR or not. COVID-19 is highly transmissible, particularly during CPR which involves numerous aerosol-generating procedures including chest compressions, endotracheal intubation, and positive-pressure ventilation (12). Therefore, many hospitals require code responders to don personal protective equipment (PPE) to safeguard against COVID-19 despite consequential delays worsening outcomes (13). Several Belgian Medical Societies declared that resuscitation should not be started or continued when provider safety cannot be sufficiently assured (14). Compromising the safety of healthcare workers (12) diminishes a hospital’s capacity to care for current and future patients (15) and also threatens relatives, colleagues, and the community (16).

During the present pandemic with resources overwhelmed, patients who ordinarily would have survived probably died because of the lack of ventilators, ICU beds, and/or CPR. Physicians have an ethical responsibility to do their best for each individual patient respecting and assisting patient autonomy. Deontologic ethics emphasize the value of each individual to receive an equal chance of life-saving care using for example “first come, first served” criteria. During a pandemic with insufficient resources to treat everyone, utilitarian ethics implementing equitable and just procedures for saving the most lives is more appropriate even when patient wishes cannot be honored (17).

If there are insufficient ICU beds to care for all critically ill patients, how should decisions be made regarding who will undergo CPR or receive the ICU bed? Almost all patients undergoing CPR require mechanical ventilation and ICU beds. Perhaps COVID-19 patients with such a high mortality should be excluded? Although patients might survive after withholding some life-sustaining treatments, denying a patient CPR would mean certain death. Although categorical exclusion criteria such as age and severe underlying disease can identify patients who are unlikely to survive, they have not been recommended to exclude patients with specific diseases from receiving CPR, including COVID-19 (15). The situation may be different under crisis settings when a fair and just triage system for allocating scarce resources is required (17). Therefore, patients with or without COVID-19 with a poor predicted survival receive low priority and are triaged not to receive an ICU bed or ventilator (17) making CPR pointless. Performing CPR in these patients places further constraints on an already stretched healthcare system with a potentially greater mortality for other patients (16).

Currently, more people are asking whether they should undergo mechanical ventilation or CPR. Today more than ever, clarifications of advanced directives and discussions of goals of care and advance care planning including ventilation and resuscitation are appropriate for all elderly patients and those with chronic diseases, especially when hospitalization is required (18). Many patients and families will appreciate these conversations and opt for palliative care knowing they will receive excellent comfort care if they deteriorate. If a physician concludes CPR is not indicated, informed assent by a patient or family may allow the doctor to take responsibility for the decision and preserve some degree of autonomy (18).

Although medical resources were and continue to be overwhelmed in several countries during the current pandemic, national guidelines for allocating scarce resources for critically ill patients, to my knowledge, do not exist except in Israel (19). As it is unlikely that such guidelines will be developed in the short term, institutions and organizations should develop clear policies to assist frontline providers in making triage decisions including CPR to promote consistency and reduce moral distress (17). Notwithstanding the fact that these policies will be controversial without straightforward solutions, I offer several suggestions. Although broad categorizations may be too expansive for specific patient decisions, hopefully, the general approach below will prove useful for IHCA during the pandemic and afterwards. The decision to perform CPR or not will depend on several considerations including: 1) the patient (advanced directives, age, severity and course of acute and chronic illnesses, cardiac arrest cause, location, and cardiac rhythm), 2) risk to the staff, and 3) severity of resource shortages (ICU beds, ventilators, and trained staff) (Table 2). The risk to staff and severity of the resource shortages will be the main determinants; however, modifications may be necessary based on local culture, practice, and laws. As the mortalities at the beginning of the pandemic were very high and might change in time, the present suggestions may require updating. Critical but more controversial questions include what should be the definition of an extreme resource shortage and what should be the trigger?

TABLE 2. - Factors Important in the Decision to Perform CPR or Not
Point in Time Considerations Suggestions
No pandemic, normal situation with adequate resources 1) Patient Determine advance directives and advance care planning.
 Goals of care
 Severity and course of acute/chronic illness Consider CPR despite severe and/or downhill course of illness.
Withhold CPR in a dying patient with an irreversible downhill course.
 Cardiac arrest rhythm and location Consider CPR for most patients regardless of the rhythm or location.
2) Risk to the staff Not applicable under most situations.
Conventional and contingency surge with moderate to high COVID-19 prevalence with adequate resources 1) Patient
 Goals of care Determine advance directives and advance care planning.
 Severity and course of acute/chronic illness Withhold CPR in a dying patient with an irreversible downhill course regardless of COVID-19 status.
Consider CPR despite severe and/or downhill course of illness regardless of COVID-19 status.
 Cardiac arrest rhythm and location Consider CPR especially if shockable rhythm or in ICU regardless of COVID-19 status.
2) Risk to the staff Resuscitation should only begin after healthcare workers have donned appropriate PPE. CPR should not be provided if proper PPE is unavailable. Code teams should have the minimum number of healthcare workers and those recovered from COVID-19 and/or vaccinated, if possible.
Crisis surge with existing shortage of resources 1) Patient
 Goals of care Determine advance directives and advance care planning.
 Severity and course of acute/chronic illness Withhold CPR in a dying patient with an irreversible downhill course regardless of COVID-19 status.
Withhold CPR if extremely severe and/or downhill course of illness regardless of COVID-19 status.
 Cardiac arrest rhythm and location Withhold CPR even if shockable rhythm or in ICU regardless of COVID-19 status.
2) Risk to the staff Resuscitation should only begin after healthcare workers have donned appropriate PPE. CPR should not be provided if proper PPE is unavailable. Code teams should have the minimum number of healthcare workers and those recovered from COVID-19 and/or vaccinated, if possible.
COVID-19 = coronavirus disease 2019, CPR = cardiopulmonary resuscitation, PPE = personal protective equipment.
Resources include ICU beds, ventilators, and PPE.

  • No matter what the situation, healthcare workers should ascertain upon hospital admission if patients have advanced directives and determine their goals of care and preferences if they deteriorate. How many intensivists have treated severely ill, chronic patients followed as outpatients for months and even previously admitted to the ICU who never had a discussion about goals and medical preferences? In normal times, but especially during a pandemic, these discussions are essential. Identifying a patient’s desires concerning life-sustaining treatments can avoid unwanted interventions and distress, but more importantly during a pandemic can also avoid endangering the staff’s health and prevent the needless use of scarce resources (18).
  • During “normal” or pandemic times of conventional or contingency capacity with adequate resources, CPR should be considered for patients with acute or chronic illnesses despite its severity and/or downhill course regardless of COVID-19 status. During pandemic times, CPR should be considered especially for patients with shockable rhythms or in the ICU regardless of COVID-19 status. During “normal” times, CPR should be considered for most patients regardless of the rhythm or location.
  • During a pandemic (or mass disaster) time of crisis capacity with extreme resource shortages, CPR should usually be denied for patients with severe acute or chronic illnesses and/or a downhill course regardless of COVID-19 status. CPR should usually also be denied even for patients with a shockable rhythm or in the ICU (except perhaps witnessed ventricular tachycardia/ventricular fibrillation in the catheterization laboratory or elsewhere when the patient may regain consciousness immediately after defibrillation) regardless of COVID-19 status. Resources should be used to maximize lives saved, for patients most likely to benefit.
  • If a decision is made not to provide CPR, the patient or family should be informed.
  • In patients with confirmed or suspected COVID-19, resuscitation should only begin after healthcare workers have donned appropriate PPE. CPR should not be provided if proper PPE is unavailable. Code teams should have the minimum number of healthcare workers and those recovered from COVID-19 and/or vaccinated, if possible.
  • Although higher mortalities are noted in the elderly after CPR, age and other categorical exclusions should not be used alone to determine resuscitation status of patients.

The current pandemic provides lessons for reassessing our prepandemic practices. CPR could be justifiably withheld when a patient is dying, and resuscitation will not prevent the inevitable death (e.g., patients in shock or respiratory failure unresponsive to therapy). We must also remember the high cost of moral distress and burnout inflicted on the staff by performing CPR in situations with high mortalities, especially during the current endless pandemic marathon.

ACKNOWLEDGMENT

I thank my good friends and colleagues who reviewed this editorial and added several important suggestions.

REFERENCES

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Keywords:

cardiopulmonary resuscitation; coronavirus disease 2019; coronavirus disease 2019 pandemic; in-hospital cardiac arrest; mortality

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