COMMENTARY

CPR for ESRD Patients? It's Time to Talk…

Jeffrey S. Berns, MD

Disclosures

June 10, 2015

Editorial Collaboration

Medscape &

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Hello. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology. Most nephrologists, at least once in their career if not many more times, have had a dialysis patient in the hospital who has had cardiopulmonary resuscitation (CPR) performed when it probably wasn't the best thing to do. It turns out that this is not uncommon.

A recent paper in JAMA Internal Medicine by Susan Wong and colleagues,[1] including Yoshio Hall and Ann O'Hare, looks at the incidence and outcomes of in-hospital CPR among dialysis patients. They used the United States Renal Data System (USRDS) registry to study over 660,000 patients. They excluded patients who received CPR in the emergency department, so the total number receiving CPR is probably higher than they report.

Of the 663,734 patients studied, 81% were hospitalized at least once. Of those who were hospitalized, 6.3% had at least one episode of CPR in the hospital. This represents an event rate of 1.4 CPR events per 1000 patient days. CPR was more common in men than in women, in black patients than in white, and, interestingly, in patients under 65 years than in those over 65.

The event rate is about 20 times the incidence of CPR in the general population. It is even quite a bit higher than a sort of disease-matched but non-end-stage renal disease (ESRD) control population.

In-hospital CPR for ESRD patients is common, and it has been increasing in incidence over the years. The investigators studied the period between January 1, 2000, and December 31, 2010. The incidence of CPR for ESRD patients increased significantly during that time. About 22% of the patients survived a hospital discharge—not very many but not an insignificant number. Of those who survived, the median survival after hospital discharge was only 5 months, although 31% of patients did survive for more than a year. What we don't know about is the quality of life that these patients experienced after hospital discharge.

We all know that CPR is performed inappropriately in all types of hospitalized patients, not just those who are on dialysis. It is also well known that many patients who receive dialysis have unrealistic expectations about the likely outcome of CPR and do not have advanced directives. They receive inappropriately aggressive care, when not performing CPR might have been the better approach had they had some sort of treatment-limiting advance directive in place.

The study points out the tremendous opportunity we have as nephrologists to work with our patients and their families to teach them about end-of-life issues, about advance directives, and about code status matters. We can help them establish an appropriate level of care so that when unforetold events occur in the hospital, such as sudden cardiac arrest, CPR is not performed if it is not appropriate for the patient, or is something that the patient or the family would not desire at such time but just had not foreseen, anticipated, and dealt with in advance.

It's something to think about and to talk to your patients and their families about. Hopefully we can all do a bit better in making sure that our patients with ESRD and other significant comorbidities have appropriate advance directives in place.

Thanks for listening. This is Jeffrey Berns from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, editor-in-chief of Medscape Nephrology.

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