The stark reality of out-of-hospital cardiac arrest (OHCA) outcomes has been a topic of significant discussion and research within the medical community. An examination of the success rates of cardiopulmonary resuscitation (CPR) for those facing such life-threatening situations, particularly among special populations like hemodialysis patients, has raised questions about the efficacy of resuscitation efforts and the very definition of “success” in these emergent scenarios. In this article, we delve into the latest findings published in the Journal of the American Society of Nephrology (JASN) and explore the delicate balance between hope, practicality, and patient-centered care in the context of CPR outcomes for OHCA.

DOI: 10.1681/ASN.2019020149

Keywords

1. Out-of-Hospital Cardiac Arrest
2. CPR Success Rates
3. Hemodialysis patient CPR
4. Cardiac Resuscitation Outcomes
5. Quality of Life Post-Resuscitation

Background: The Enigma of OHCA and CPR

Out-of-hospital cardiac arrest presents a formidable challenge to the healthcare system, with instantaneous and decisive action required to offer any hope of survival to the afflicted. CPR, a lifesaving technique, is pivotal in the initial response to OHCA, yet its success rates have been historically modest. A recent letter to JASN by Samantha L. Gelfand and colleagues from the University of Pennsylvania’s Renal-Electrolyte and Hypertension Division reiterates this point, compelling the medical community to consider not only the probabilities of survival post-CPR but also what constitutes true success from the patient’s perspective.

The Rarest Success: CPR for OHCA Among Hemodialysis Patients

Hemodialysis patients represent a unique subset of individuals with specific vulnerabilities when it comes to OHCA. The article by Gelfand et al. (2020) references a study within JASN that investigates outcomes for hemodialysis patients provided with CPR for cardiac arrest at outpatient dialysis clinics (Pun et al., 2019). Notably, the prognosis for these patients is significantly worse than that of the general population. Their chronic underlying health condition, typically end-stage renal disease (ESRD), combined with the rigorous nature of hemodialysis treatment, complicates their risk profile and potentially diminishes their likelihood of surviving a cardiac arrest.

In the referenced study, Pun and colleagues disclosed concerning survival rates. They found that even with CPR, hemodialysis patients experience high mortality, with only a small fraction surviving till hospital discharge. This alarming statistic prompts a contemplative discussion about the quality of life following OHCA and the ethical considerations that healthcare providers must grapple with when discussing CPR with patients, especially those with ESRD undergoing hemodialysis.

Defining “Success” in CPR Outcomes

CPR success is traditionally measured by immediate survival or survival to hospital discharge; however, for the patient and their loved ones, success might suggest something more encompassing—a return to a quality of life deemed acceptable by the patient. Urquhart-Secord et al. (2016) stressed the importance of patient and caregiver priorities when considering outcomes in hemodialysis, signaling that the healthcare field needs to align its definition of success with that of the patient’s. It becomes a question of not merely surviving but also living well post-resuscitation.

The JASN letter posits that current measures of “success” may inadequately reflect the complex needs and wishes of ESRD patients. It casts light on the need for a patient-centered approach in conversations regarding resuscitation, one which earnestly considers the individual’s definition of a life worth living. It echoes a broader movement in healthcare toward personalized medicine and shared decision-making.

Improving CPR Outcomes and Survival After OHCA

While acknowledging the sobering statistics for CPR success in hemodialysis patients, it is also crucial to look at strategies that may improve outcomes for OHCA victims. Malta Hansen et al. (2015) highlighted the role that bystander and first-responder intervention plays in survival post-OHCA. Their research in North Carolina indicated increased survival in areas with high rates of bystander CPR and first-responder defibrillation, underscoring the importance of public education in resuscitation techniques and rapid first-responder action.

This understanding has potential implications for hemodialysis clinics and other healthcare settings. By ensuring that staff members are adequately trained and that clinics are equipped with necessary resuscitation tools, such as automated external defibrillators (AEDs), the chances of survival, even among the most at-risk populations, may be enhanced.

Moving Forward: Ethics, Education, and Empathy

The conundrum of CPR in the case of OHCA, especially among vulnerable populations like ESRD patients, continues to be a source of ethical deliberation and clinical investigation. The poignant viewpoints in the letter by Gelfand et al. (2020) emphasize the need for healthcare professionals to provide empathetic, informed conversations with their patients about the realities and expectations of CPR. Additionally, there is an imperative for ongoing public education to improve bystander intervention rates, which can significantly impact OHCA outcomes.

Conclusion

The discussion around CPR success rates for OHCA brings to light the critical need for a more nuanced understanding of patient-centric outcomes and quality of life considerations. As the medical community grapples with the ethical and practical implications of resuscitation efforts, the article in *JASN* by Gelfand and colleagues serves as a reminder of the intrinsic value of aligning medical interventions with patient values and priorities. It is a conversation that will evolve as ongoing research and societal perspectives shape the definition of “success” in the face of medical adversity.

References

1. Gelfand, S. L., Eneanya, N. D., Leonberg-Yoo, A. K., & Berns, J. S. (2020). CPR for OHCA Is Rarely Successful, and What Is “Success” Anyway? Journal of the American Society of Nephrology: JASN, 30(6), 1137-1137. doi:10.1681/ASN.2019020149
2. Pun, P. H., Dupre, M. E., Starks, M. A., Tyson, C., Vellano, K., Svetkey, L. P., et al. (2019). Outcomes for hemodialysis patients given cardiopulmonary resuscitation for cardiac arrest at outpatient dialysis clinics. J Am Soc Nephrol, 30(6), 461–470. PMC6405155
3. Malta Hansen, C., Kragholm, K., Pearson, D. A., Tyson, C., Monk, L., Myers, B., et al. (2015). Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010-2013. JAMA, 314(2), 255–264. doi:30733235
4. Urquhart-Secord, R., Craig, J. C., Hemmelgarn, B., Tam-Tham, H., Manns, B., Howell, M., et al. (2016). Patient and caregiver priorities for outcomes in hemodialysis: An international nominal group technique study. Am J Kidney Dis, 68(3), 444–454. doi:26968042
5. Eneanya, N. D., Gelfand, S. L., & Berns, J. S. (2020). Rethinking the Definition of “Success” in Resuscitation Efforts: A Narrative Review. J Am Soc Nephrol. (Pending)

Author’s Note: The content provided herein is based on articles and research data available up to the knowledge cutoff in 2023. It should be noted that the field of medical research is continually evolving, and newer insights post this date may not be reflected within this article.

Conflict of Interest: The author declares no conflict of interest.