Even After Death, Heart Attack Treatment May Not End
TUESDAY June 30, 2009 -- Chances of surviving a heart attack that occurs outside of a hospital are slim, but paramedics often take people who have died to a hospital anyway because a variety of factors keep them from following recommended guidelines, a new study finds.
In the United States, paramedics treat almost 300,000 people with cardiac arrest each year. But despite what's portrayed on TV, fewer than 8 percent survive, according to the American Heart Association.
The association's guidelines include the recommendation that people who have not responded to cardiopulmonary resuscitation (CPR) and advanced cardiac life support in the field not be taken to a hospital. After paramedics have tried and failed to resuscitate a patient, they should stop, researchers say.
"Paramedics provide all the same lifesaving procedures that we can provide in the emergency department," said the study's lead researcher, Dr. Comilla Sasson, Robert Wood Johnson clinical scholar and clinical lecturer in emergency medicine at the University of Michigan Medical School.
"Once you have done 20 to 30 minutes of cardiac resuscitation, the best practice guidelines are to cease if a patient does not have a pulse," she said. But the study, published online June 30 in Circulation: Cardiovascular Quality and Outcomes, found that several factors inhibit this from happening, including:
- Local laws that mandate procedures for paramedics and other responders
- Insurance policies that allow higher reimbursement when someone is taken to a hospital
- Public misperception about the odds of survival
"When you look at TV shows, 90 to 95 percent of the people survive cardiac arrest," Sasson said. "In reality, it's less than 8 percent, so there is a big disconnect about what people understand about cardiac arrest survival and what happens in the real world."
She said that paramedics often feel pressured by these expectations to transport the patient to a hospital. What people don't realize, Sasson said, is that the care paramedics provide in the field is exactly the same treatment that the patient would receive in the hospital.
Another problem, Sasson said, is that health insurers -- including Medicare -- pay less for paramedic care than for care in a hospital. "There is a large financial disincentive for paramedics to stay on scene," she said.
Also, she said, some states "mandate that every cardiac arrest patient get transported to the hospital." And some require that even people with do-not-resuscitate orders must be treated if the person does not have the proper state form in his or her possession, she said.
Taking people to a hospital needlessly for treatment also creates what Sasson described as an opportunity cost.
"When you bring in a patient that is essentially dead, all of your resources go to that patient, which leaves the rest of the emergency department unmanned," she said. "When you are trying to resuscitate someone who should have never been transported to the hospital in the first place, you are shifting away resources from people who actually have conditions that are treatable."
The findings explained by Sasson stemmed from three small focus groups, including emergency physicians and emergency medical services (EMS) directors, conducted during the 2008 National Association of Emergency Medical Services Physicians meeting in Jacksonville, Fla.
Sasson and her fellow researchers concluded that, to help solve the problems pointed out by the focus group members, state laws need to be brought into line with American Heart Association guidelines and payment for paramedic care needs to be based on the care that's given, not on where it's given. Also, she said, the public needs to be made more aware of the realities of surviving a heart attack.
Dr. Kathleen Schrank, a professor of medicine and chief of emergency medicine at the University of Miami Miller School of Medicine -- and also an EMS medical director for Miami Fire Rescue -- said she agrees that barriers to stopping resuscitation exist.
Public perception that most people survive a cardiac arrest is a particular problem, Schrank said.
"Families have not only the hope but the expectation that their loved one is going to survive," she said. "They think that the emergency department has more to offer than what EMS can do."
She pointed out, though, that exceptions to stopping resuscitation do exist -- including children and pregnant women, in cases where the fetus might survive.
But Schrank noted that every situation is different and that paramedics and the doctors they're communicating with via radio need to be sensitive as they prepare family members to accept that their loved one has died and need not be taken to a hospital.
By American Heart Association guidelines, a decision to stop resuscitation should be based on clinical judgment and respect for human dignity. Also, stopping lifesaving efforts should be approved by a doctor who is in contact with paramedics by radio, the guidelines say.
"Most families, when they see all the things a rescue crew goes through trying to save a person in cardiac arrest, usually do recognize that everything was done," Schrank said.
Posted: June 2009
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