Survivorship & Psychological Wellbeing After Cardiac Arrest
Cardiopulmonary resuscitation (CPR) was transformative at its inception, yet neither the technique nor its success rate has changed significantly since that time. CPR is physically difficult, prone to variations in execution, and in most cases, 75 percent of those who are initially saved die within hours to days, such that only 5 to 10 percent of people who receive CPR in the community and only 20 percent of those who receive CPR in hospitals are able to survive and be discharged from the hospital. Today, CPR can be viewed similarly to the way one might consider a Model T Ford, which represented a significant leap in innovation over its predecessors upon its introduction in the early 20th century, but pales in comparison to the performance vehicles of today.
The Model T analogy is apt from a biological perspective as well—CPR can certainly reverse death in select circumstances, but it cannot remotely match the performance of the human heart and lungs. Even when performed under “optimal” conditions, CPR itself is unable to circulate enough oxygen to meet the high metabolic needs of the brain, a reality that is complicated by the fact that cardiac arrest is a rapidly evolving condition that changes by the minute.
In the absence of adequate oxygen, a cascade of chemical and pathological processes is triggered throughout the body, producing systemic inflammation and causing cells and organs to undergo damage. The further this process progresses, the more difficult it is to reverse. Many people who are successfully resuscitated have significant long term issues including brain injury, functional deficits, and psychological and cognitive deficits, such as post-traumatic stress disorder (PTSD), anxiety, depression, and memory loss.
Due in part to the limitations of CPR, the best probability of survival with CPR is seen in those patients who are able to be resuscitated quickly. Often these are people whose cardiac arrest was caused by a disorder that could be treated quickly—typically less than five minutes after the onset of cardiac arrest. Approximately 70 percent of people who respond to CPR within 5 minutes may survive and have minimal or no brain injury, but the odds of successful resuscitation—particularly without brain injury—decline precipitously after the 10 to 15-minute mark if nothing is done to augment and improve CPR.
Saving a patient’s life is the most important focus of emergency care physicians. However, as more patients are successfully resuscitated, it is vital to consider the long-term mental health and psychological consequences of survivors. The goal of any critical care team is to not just restore blood flow and brain activity, but to discharge patients who are capable of reentering their day to day lives in a meaningful way.
Decades of research has indicated that cardiac arrest survivors experience a spectrum of psychological after-effects. Some 15 to 50 percent report adverse outcomes such as PTSD, memory deficit, cognitive difficulties, anxiety, or depression. Yet 10 to 20 percent of survivors report positive outcomes that transform their perspective about life and death, and often result in more altruistic outlooks and less fear of death.
The characteristics and factors associated with these two categories have not been studied sufficiently, leaving physicians without best practices to try to optimize patients’ post-cardiac arrest psychological wellbeing and outlook. In tandem with our AWAreness during REsuscitation (AWARE II) study and our work exploring the psychological consequences of cardiac arrest, we are pioneering robust research programs to explore the prevalence of positive and negative outcomes and the impact they have on quality of life and survivorship.