Please don’t resuscitate me

A follow-up of 6,972 people aged 64 years and older who had undergone a cardio respiratory arrest whilst they were hospitalised in an inpatient facility showed that the survival rate, after one year from the attack, was barely 10%, and if this estimate was restricted to people with no neurological injuries, the rate was halved. We don’t have data on the mid and long-term results for older people who are resuscitated outside of the hospital, but it all seems to be worse.

Aware of the bad omens of the heart failures at an advanced age, John Ballard, a retiree born and raised in the southern US, and an old fashioned liberal, as he defines himself, answered a tweet of mine on his blog in this manner:

Cardiopulmonar Resuscitation in elder: the mirage of numbers https://t.co/bwGhtULUV6 pic.twitter.com/lpiG5egsOd

— Jordi Varela (@gesclinvarela) 17 de enero de 2017

@gesclinvarela @maggiemahar I carry a DNR in my wallet.https://t.co/5VMPKC8Njq

— John Ballard (@Hootsbudy) 19 de enero de 2017

Doctors strikes and medical congresses = less mortality

At a doctors' strike in Israel in 2000, the gravediggers noticed that their workload diminished in areas where the doctors’ strike was on, while it remained unchanged in areas where doctors did not adhere. Judy Siegel-Itzkovich, scientific editor of the Jerusalem Post, in a letter called “Doctors' strike in Israel may be good for health”  attributed the phenomenon to the shutdown of the scheduled surgery, which probably brings improvements of certain ailments, but which, by itself, can lead to complications and mortality. A few years later, in “Doctors' strikes and mortality: a review”, a systematic review of 156 papers analyzing the mortality impact of several doctors' strikes around the world, shows that during the doctors’ strikes, the population mortality either remains unchanged or lowers, but it never rises. The authors of the paper, like the Jewish publisher, also think that the phenomenon is an indirect measurement of the surgical over activity so common in clinical practice that, curiously, is shown when the programmed activity ceases drastically during a certain period.

Cardiopulmonary Resuscitation for older people: the mirage of numbers

New England Journal of Medicine published a study in March 2013, promoted by a group of researchers from the American Heart Association. It was a study performed with a sample of 6,972 people over 64 years who had been discharged in the period 2000-2008 after having survived a cardiac arrest during hospitalization. According to the study, 58.5% of the patients were still alive one year after discharge from hospital. The results, however, were significantly worse in the subgroup of 84 years plus (49.7%) and those who had suffered severe neurological sequels (42.2%) or had been in a vegetative coma (10.2%). The conclusions of this study, therefore, are favourable for the practice of cardiopulmonary resuscitation (CPR) during the cardiac arrest of the elderly. GeriPal, a blog of geriatrics and palliative care represented them in the "icon-box" that you can see above.

Measuring results in health is still very complicated

In order to evaluate health institutions based on the value they provide, health outcomes must be measured. However the efforts to achieve this are bearing dismal results. Pay-for-performance initiatives are drifting in an ocean of indicators that don’t translate into anything too operational. To give some examples, in the US, CMS (Medicare and Medicaid) handles nearly a thousand indicators to promote new funding models (see Health Affairs Blog "The Quality Tower of Babel") and, not so far away, in the Results Central of Catalonia (AQuAS), more than 300 indicators are recorded. Everything suggests that the excess of information will not bring light if we are not able to clarify what it means to add value to people's health, and to make this statement comprehensible, we must distinguish between two different approaches:

Health value for citizens

A long life free of disability is a goal that most mortals share but this indicator is not very useful for service providers because the impact of the health system on life expectancy barely reaches 20%.

The soul of healthcare institutions

Professional groups, just like any other groups, have a soul or, as they now like to say, values. But whenever they try to write down these values, every group finds it difficult to find the words that express what unites them, what makes them say: "This woman/man will succeed, she/he’s ours." When professionals are immersed in a stimulating project or when they work in a team, it takes only a few words to understand each other, most people know this feeling especially when contrasting it with the feeling they get when they perform a job that doesn’t interest them so they end up literally counting the hours until the end.

"The Sprit of the Clinic"

There are few health institutions that have put effort into preserving their soul, being aware of how values are prone to oblivion and of how little the excellence of a unit lasts when effort goes unrewarded with the arrival of a new boss who sees things differently from how they are. For this reason, I have always admired the consistency of Mayo Clinic governance. It’s an institution created in 1892 by the Mayo brothers that has successfully overcome two major challenges: generational change and the entry of foreign capital (for more details see post of June 23, 2014). We must mention that, in recognition of the Mayo Clinic, most comparable projects have not overcome the challenges posed to the survival of values in the US or anywhere else. And how did the Mayo clinic do it? The answer is as simple as it is complex: "The Spirit of the Clinic" determines professional careers and the professionals’ progress; on the other hand, there’s nothing too different to how the great religions have survived over millennia.