Despite multiple advances in critical care medicine and cardiac life support, cancer patients’ survival following CPA in the ICU remains poor . In our study, CPA outcome predictors in 104 critically ill cancer patients in a comprehensive cancer center were evaluated. About one third of the cohort (34.6%) survived the initial CPA but only 1 in 20 patients (5.8%) survived to hospital discharge. Developing acute kidney injury or refractory shock, being on mechanical ventilation and CPR duration predicted resuscitation failure meanwhile requiring mechanical ventilation and CPR duration predicted poor hospital outcome. Cancer patients who suffered CPA in the ICU had a 10% increase in mortality per minute of resuscitation.
A meta-analysis of 42 studies, the vast majority of which were carried-out in developed countries, examined survival in 1707 cancer patients who underwent in-hospital CPR reported an overall hospital survival of 6.2% (95% CI: 3.2 – 9.1) . ICU survival rate in the pooled data was 2.2% (95% CI: 0 – 4.6), findings that are consistent with ours.
Predictors of in-hospital CPA outcome were reported by several investigators [1, 3, 9–14]. Survival was significantly low in unwitnessed arrests, in anticipated arrests, after PEA/asystole arrests, and if the resuscitation efforts lasted longer than 10 minutes. Furthermore, in cancer patients, poor functional status at baseline, metastatic disease and hematological malignancies carried grim prognosis [8, 15]. As an initial cardiac rhythm, all but two of our study subjects had PEA or asystole which precluded further testing of initial rhythm’s effect on outcome. Cardiac arrests in our study developed in the ICU setting, hence, were all witnessed. There is no agreed upon definition for “anticipated CPA”. Anticipated CPA defined as having refractory shock, refractory respiratory failure and/or multiorgan dysfunction syndrome did not predict CPR failure or hospital outcome. In line with previous studies, our data could not identify a significant relation between age and CPA outcome. In our data, CPR duration had a strong association with outcome and it has been previously used in the derivation of a clinical decision rule to discontinue resuscitation efforts in CPA inpatients . The rule included initial cardiac rhythm and whether the arrest was witnessed.
Patients with hematological malignancies are less likely to survive a CPA compared with patients with solid tumors . In our study, patients with hematological malignancies were more likely to survive a first CPA but none survived to hospital discharge. In comparison to patients with solid tumors, those with hematological malignancies were relatively younger but were more likely to be on mechanical ventilation and more likely to require vasopressor support.
Culture and religion are among a multitude of factors that influence end-of-life decisions . They impact the perception and behavior of patients and their treating physicians . In Jordan, like it is the case in the Middle East and some Southern and Eastern European countries, the principles of beneficence and non-malfeasance outweigh patient autonomy and play a predominant role in the process of decision making . Moreover, illness in some of those countries is considered to be a shared family affair complicating end-of-life-discussions furthermore .
Apropos to the above, code status discussions were documented in 11% of our patients, a small percentage in light of how critically ill the cohort was; 82% on mechanical ventilation and 74% on vasopressors. The development of palliative care medicine has made wide strides in Jordan but, for the reasons alluded to above, end of life discussions remains a sensitive topic . Although it is easy for patients and families to understand the “do-not-resuscitate” (DNR) concept, they find it a very difficult choice to accept. Cultural beliefs and some religious misconceptions stand behind this sense of guilt and discomfort. To overcome this, some physicians have resorted to their legal and religious background and do not present DNR status as a choice, rather a medical decision that the family is informed of . With globalization and as the number of Western-trained physicians increase, a change in how end-of-life-discussion is handled in this part of the world is to be expected. In fact, this has already been reported by some of the most recent publications .
The present study has several limitations. Its retrospective nature introduced a selection bias by including patients who underwent CPR, but not those who had a CPA but were not resuscitated because of a DNR code status. Due to lack of testing and adequate documentation, the study did not include some of the well described predictors of CPA survival like end-tidal carbon dioxide levels during CPR and baseline functional status of patients. The small number of cases in a single-center and the specificity of the patient population studied “critically ill cancer patients” are other limitations too; this prevents generalizability and requires further validation.