Resuscitation in Care Homes

Emergency physicians called to resuscitate elderly patients in care homes often find themselves in a situation of uncertainty. In many cases the patient’s wishes are unknown and no advance directive is available. This presents the physician with difficult ethical dilemmas.

The care home staff are also affected by uncertainty and commonly delay resuscitation attempts. This further worsens the already extremely slender chance of survival with a good neurological outcome.

Increasing demand for care

Recent demographic trends imply that the number of multimorbid elderly patients who need to be accommodated in nursing homes in Germany can be expected to increase. In order to cope with this development in a way that meets patients’ wishes, a concept is urgently required that enables anticipatory health care planning for future emergencies.

One such concept, advanced care planning (ACP), is already anchored in German law (§ 132g of the Statutory Health Insurance Act [German Social Code V], passed in 2015) (1). However, targeted information of patients about the opportunities and risks of resuscitation, as well as communication with their relatives—and, if applicable, their appointed representatives—requires solid facts that put the patient or representative in a position to decide for or against resuscitation in emergency situations.

The article by Günther et al. (2) tackles this problem and presents the first ever retrospective analysis of the outcome after prehospital resuscitation in German care homes over the period 2011 to 2018, based on data from the German Resuscitation Registry (2).

Advance care planning: fact-based guidance

In their article Günther et al. present recent data on stratified survival rates and the neurological outcome in the shape of fact boxes. These form the basis for consultative discussions between patients and medical staff. The aim is to enable patients to make individual advance decisions regarding critical life situations and also to strengthen their autonomy. The existence of established data facilitates discussions not only with patients and their relatives but also with the care home staff.

Because no recent research data are available on the situation in German care homes or on the German emergency rescue services—and otherwise only a small number of publications from France, the USA, and Australia—the work by Günther et al. deserves appreciation.

Along with the retrospective design, a major methodological limitation that has to be borne in mind when interpreting the findings is that analysis was restricted to cases from institutions that contribute to the resuscitation registry. No account is taken of regional differences arising from variations in emergency rescue service structures, provision of primary care, and training of care staff in the homes.

Resuscitation by lay persons

Campaigns for training of lay persons in resuscitation techniques, such as the annual “Resuscitation Week” initiated by professional societies and the implementation of resuscitation algorithms in school tuition have placed the topic of resuscitation at the center of public life. The current European Resuscitation Council guidelines, however, highlight not just the correct technique for resuscitation but also the option of deliberately discontinuing efforts at resuscitation—in terms of honoring the patient’s known or presumed wishes and considering the risk of permanent dependence on care (3).

In view of the constantly aging population, the rising number of (emergency) rescue service deployments in care homes, and the desire to maximize patient autonomy with regard to decisions in critical situations, this article provides valuable new data. The research is also particularly relevant to the debate about ACP during the ongoing COVID-19 pandemic (4).

Save lives and reduce suffering

Alongside saving lives, a major duty of the attending rescue service personnel or emergency physician is to reduce suffering. Therefore, before initiating resuscitation one must consider, as an alternative, deliberately omitting any attempt to revive the patient and pursuing a palliative policy instead.

At all times of day the attending rescue service personnel/emergency physician must have immediate access to the relevant information, e.g., in a documentation folder. This is dictated by the obligations of patient care and courtesy to fellow professionals. The outcome data in Günther et al.’s study are also of great significance in such decisions.

Uncertainty about the patient’s wishes with regard to resuscitation or palliative care may be a contributory reason why care staff do not always initiate resuscitation measures before the emergency physician arrives. This ethically challenging situation underlines the ongoing importance, both for the patient and for the care staff and physicians involved, of individual advance planning for treatment in emergencies.