Elsevier

Resuscitation

Volume 85, Issue 3, March 2014, Pages 369-375
Resuscitation

Clinical Paper
Resuscitation of patients suffering from sudden cardiac arrests in nursing homes is not futile

https://doi.org/10.1016/j.resuscitation.2013.10.033Get rights and content

Abstract

Background

Survival after out-of-hospital cardiac arrest (OHCA) has increased in recent years, and new data are therefore needed to avoid unsubstantiated statements when debating futility of resuscitation attempts following OHCA in nursing home (NH)-residents. We aimed to investigate the outcome and prognosis after OHCA in NH.

Methods

Consecutive Emergency Medical Service (EMS) attended OHCA-patients in Copenhagen during 2007–2011 were included. Utstein-criteria for pre-hospital data and review of individual patient charts for in-hospital post-resuscitation care were collected.

Results

A total of 2541 consecutive OHCA-patients were recorded, 245 (10%) of who were current NH-residents. NH-patients were older, more frequently female, had more witnessed arrests, fewer shockable primary rhythm and assumed cardiac aetiology, but shorter time to the return of spontaneous circulation (ROSC) compared to OHCA in non-nursing homes (non-NH). Overall 30-day survival rate was 9% in NH and 18% in non-NH, p < 0.001. Of the 245 NH-arrests 79 (32%) patients were admitted to hospital compared to 937 (41%) from non-NH (p < 0.001). Thirty-day survival rate in patients admitted to hospital were 27% for NH- and 42% for non-NH-patients, p < 0.001. OHCA in NH was, however, not associated with a significantly worse prognosis (HR = 0.88 (0.64–1.21), p = 0.4) after adjustment for known prognostic factors including co-morbidity.

Conclusions

Nursing home residents resuscitated from OHCA and admitted to hospital have similar survival rates as non-NH-patients when adjusting for known prognostic factors and pre-existing co-morbidity. A policy of not attempting resuscitation in nursing homes at all may therefore not be justified.

Introduction

Out-of-hospital cardiac arrest (OHCA) remains associated with a poor prognosis even after patients are successfully resuscitated and admitted to hospital, only 5–10% are alive after 30 days.1, 2, 3 Automated external defibrillators (AEDs) have been shown to increase survival after OHCA due to fast reversal of a shockable primary rhythm with defibrillation, and to improve survival strategic placements of AEDs have been in focus in recent years.4, 5

It is well known that younger age and less comorbidity are prognostic factors for a good outcome after OHCA and as nursing home (NH) residents in general are older, often have pre-existing comorbidities and have a higher susceptibility to critical illness, ethical dilemmas may arise regarding whether resuscitation attempts are futile and therefore should not be initiated in case of arrest.6, 7, 8, 9 Previous studies found very few or none survivors among NH-residents suffering from OHCA.10, 11, 12, 13, 14, 15, 16

However, other studies found that OHCA-patients in NH with witnessed arrest and shockable primary rhythm at arrival of the Emergency Medical Service (EMS) have comparable survival rates with elderly citizens outside NH.17, 18 Research has identified locations with multiple cardiac arrests in an attempt to maximize the effectiveness of AEDs, and NH has been identified as such a multiple cardiac arrest location.13, 19, 20, 21 Some countries such as Japan and some states in the USA have therefore placed AEDs in NH, but discussions about quantity vs. quality of life may arise.20, 21, 22, 23

Survival after OHCA has increased in recent years but contemporary data in the European setting are needed to document if this is also the case for OHCA occurring in NHs and to avoid unsubstantiated statements when debating resuscitation of OHCA in NH-residents.1, 10, 11, 12, 13, 14, 15, 24 The aim of this study was to investigate the outcome and prognosis after OHCA in nursing homes compared to non-nursing homes (non-NH) in the greater Copenhagen area.

Section snippets

Patients and study area

Data for this cohort study were consecutively collected from 2007 to 2011. Patients older than 18 years with OHCA of all causes in the greater Copenhagen area and EMS dispatched and attended were included. Patients with obvious signs of death (e.g. rigour/livor mortis) (n = 1179) and non-Danish residents (n = 59) were excluded due to the non-obtainable outcome data on these patients.

The EMS in Copenhagen, the capital of Denmark, covers the Copenhagen area of 675 km2 (260 mi2), which is inhabited by a

OHCA with attempted resuscitation

The EMS in central Copenhagen attended a total of 3720 consecutive out-of-hospital cardiac arrests in the study period (2007–2011), and of those were 2541 patients (incidence: approx. 0.04%/year) attempted resuscitated, Fig. 1.31 Ten per cent of the arrests (n = 245) occurred in citizens living in NH, corresponding to 49 arrests per year in the study period. In the greater Copenhagen area approximately 3500 citizens were living in NH in the study period, corresponding to 0.3% of the population

Discussion

In this study we found that sudden OHCA in nursing homes was associated with a significantly lower survival rate compared to OHCA in the general population, with 9% of NH-patients being alive after 30 days as opposed to 18% in non-NH-patients.10, 11, 12, 13, 14, 15 However, after adjustment for known prognostic factors, age and co-morbidity no significant difference in survival was found. These contemporary data on outcome after OHCA in NH are important and essential for decision-making and for

Conclusion

Residents suffering an OHCA in nursing homes die more often compared to OHCA arrests occurring outside nursing homes. However, after successful resuscitation and admission to the hospital no significant association between survival in non-NH-patients and NH-patients following OHCA was found, when adjusting for known prognostic factors, including age and pre-existing co-morbidity. A policy of not attempting resuscitation in nursing homes at all may therefore not be justified.

Conflict of interest statement

None.

Acknowledgements

None.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.10.033.

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