Resident Survival Low After Cardiac Arrest in Nursing Homes

Abstract

At 30 days, survival after out-of-hospital cardiac arrest (OHCA) was 1.7% among nursing home residents, although those who received resuscitation efforts had an increased likelihood of survival, according to the results of a Danish study. “Nursing home residents are often of high age and have significant comorbidity burden. As a consequence, it is often debated whether resuscitative efforts and placement of automated external defibrillators (AEDs) in nursing homes are futile,” study investigator Marianne Pape, MD, of the Aalborg University Hospital in Aalborg, Denmark, and her colleagues wrote. To better understand survival among nursing home residents who experience OHCA and the impact of resuscitative efforts, Dr. Pape and her fellow researchers conducted a nationwide, follow-up study using Danish Cardiac Arrest Register data (Resuscitation 2018;125;90–98). The study included patients 18 years and older with OHCA who had undergone a resuscitation attempt in a nursing home or private home from June 1, 2001 to Dec. 31, 2014. Thirty-day survival after OHCA served as the primary outcome, and 30-day survival in the best- and worst-case scenarios was the secondary endpoint. The researchers defined the best-case scenario as a witnessed cardiac arrest, bystander cardiopulmonary resuscitation (CPR), and prehospital defibrillation; the worst-case scenario was defined as an unwitnessed cardiac arrest, no bystander CPR, and no prehospital defibrillation. From a population of 45,293 patients with OHCA in whom resuscitation was attempted, 26,999 were included in the study. Of these patients, 9.3% experienced an OHCA in a nursing home (median age 83 years) compared with 90.7% who experienced an OHCA in a private home (median age 71 years). The nursing home residents were more often female and were more likely to have chronic obstructive pulmonary disease, previous stroke, dementia, a witnessed arrest, and bystander-initiated CPR. In addition, a higher rate of patients in private homes experienced a shockable heart rhythm upon emergency medical service (EMS) arrival and EMS life-support treatment resulting in EMS defibrillation, whereas bystander defibrillation was similar between groups. Overall, among nursing home residents the 30-day survival was 1.7% and 1-year survival was 1.2%; for private home residents, the rates were 4.9% and 4.3%, respectively. The researchers postulated that possible reasons for this low survival rate among nursing home residents included the older age and higher comorbidity burden of this population. The independent predictors of 30-day survival for both groups were a witnessed cardiac arrest, bystander CPR, and prehospital defibrillation. The researchers noted that the rates of witnessed cardiac arrest and bystander CPR were higher in the nursing home residents. “Because nursing homes are staffed with several health care workers, it is likely that CPR was initiated immediately after recognition of arrest, and performed with a higher quality than by an elderly spouse in private homes,” they wrote. “At the same time, nursing home residents had less primary shockable heart rhythm upon EMS arrival, and received less EMS defibrillation.” The secondary endpoint analysis among the nursing home residents suggested a predicted 30-day survival probability of 7.7% in the best-case scenario and 0.1% in the worst-case scenario. For the private home residents the rates were 24.2% and 0.4%, respectively. “This supports [automated external defibrillator] deployment in nursing homes as well as private residential areas, although we emphasize the need for an active standpoint regarding DNAR-orders [do-not-attempt-resuscitation], especially in nursing homes,” the researchers wrote. The study limitations of note, according to the researchers, included the observational design, the lack of data in the registry on the quality and length of bystander CPR, and the unavailability of data on DNAR orders for nursing home and private home residents. Brian Ellis is a freelance writer and editor based in NJ. Many clinicians consider CPR to be a non-beneficial (or in the old parlance, “futile”) treatment in a sizable portion of our post-acute and long-term care patients. In other words, the chance that it will yield a benefit that the patient will appreciate is so low as to be unacceptable (paraphrasing eminent bioethicist Dr. Larry Schneiderman). But there is a wide variability in the health status and life expectancy of nursing facility residents; some may be healthy sexagenarians rehabbing from a knee replacement, while some are nonagenarians with advanced metastatic cancer. Although the overall statistic of 1.7% 30-day survival is in line with my general impressions of the success of CPR in nursing homes, it does not tell us how many of those people were still in a hospital or ICU (probably a lot), or how many were cognitively intact or functionally back to baseline (probably very few). The study also determined that when a witnessed arrest occurred and an AED was used in a nursing home, the 30-day survival rate was 7.7%. Again, we don’t know what kind of shape survivors were in, but that’s a much higher number and less suggestive of futility. The authors were trying to determine whether AEDs should be available in nursing homes, and the answer isn’t clear. In fact, out of the nursing home arrests where an AED was available, less than 10% of the patients had a shockable rhythm. On the other hand, for those who did, 7.7% of them survived for 30 days. And of course, the AED can be used on other people (visitors, staff) who suffer an arrest in the facility. —Karl Steinberg, MD, CMD, HMDC Editor in Chief