a powerful tool with serious consequences

The shocking scene that unfolded during the Bills-Bengals game Monday evening was a play that I’ve seen countless times on a very different stage. Yet as a hospital physician, watching Damar Hamlin’s on-field cardiac arrest was unexpectedly jarring. Seeing the coordinated and professional medical response on the field was inspiring. No doubt, timely and effective CPR and defibrillation saved his life. As I reflect on the events of that evening, it strikes me that Damar Hamlin’s resuscitation may have felt so different to me, in part because of how often I am called upon to use CPR ineffectively in the hospital setting. And as I take in the heavy media coverage this week promoting CPR awareness, I feel that we ought to do more to contextualize CPR as a tool: What is it like, when is it helpful, when does it cause needless suffering, and how can we do a better job of deploying it equitably in our society?

CPR can be enormously impactful when used appropriately, like any good tool or technology. Damar Hamlin is precisely the patient for whom CPR was designed: he is young, otherwise healthy, and at the peak of physical fitness. Overall, only about 12 percent of people who suffer out-of-hospital cardiac arrest survive. People who are relatively young and in good health fare better than average, and timely resuscitation and defibrillation can more than double the odds of survival. Yet not everyone has the same ready access to care that the quick-thinking team provided on Monday night. Less than half of people who suffer out-of-hospital cardiac arrest receive bystander CPR. Women suffering cardiac arrest are less likely to receive CPR than men. The disparity for Black and Hispanic individuals is even more troubling, with a 10 to 15 percent lower rate of bystander CPR compared to white individuals in home and community settings. As we promote access to CPR, we also need to examine how to make this access equitable across all communities and for all people.

For anyone who does undergo CPR, it is a major blunt-force trauma. Unfortunately, the media often depicts it as a relatively gentle procedure; this is inaccurate, and sugarcoating the side effects of CPR is misleading. In order to be at all effective, CPR must be performed rapidly and forcefully. This means broken ribs and injuries to other internal organs, such as the lungs and the pericardium, the protective sac around the heart. Damar Hamlin, young and in peak physical condition, was intubated and in critical condition three days after resuscitation, largely due to the unavoidable injuries caused by CPR. Most of us are not Damar Hamlin.

In the hospital, I talk with elderly people about their preferences for care in the event of a medical emergency. It is shocking how many have never had this conversation; and how many voice a preference for full resuscitation but think this means a simple “zap” to the heart and waking up all better. This is fiction. I have visceral memories of attempting resuscitation on people who could have been my grandparents. I have cracked their ribs like twigs beneath my hands; floated up and down on their broken chests like rafts adrift in a stormy sea. I have watched the blood pouring from their mouths and coating their white hair. It was clear that these people would not survive. Though they died with a dozen hands on their bodies, they fundamentally died alone, their passage punctuated by suffering.

My feeling is that if most people could watch these scenes play out, they would not want CPR for themselves under such circumstances. A recent nationwide survey found that 71 percent of Americans value “helping people die without pain, discomfort, and stress” over “preventing death and extending life as long as possible.” But we do a poor job of educating people about what CPR looks like and about the post-resuscitation gauntlet that awaits CPR survivors who are already sick, frail, or elderly. A 2014 analysis of studies on CPR survival for hospitalized adults over age 70 found an overall 11 to 19 percent chance of survival to hospital discharge, which decreased with advancing age. Frailty, a measure of dependence on physical and cognitive activities of daily living, dramatically decreases the odds of CPR survival. One 2019 study looking at nearly 200 inpatient cardiac arrests found that 32 percent of patients with moderate to severe frailty survived an initial resuscitative effort. Still, only 1.8 percent of patients in this category survived to hospital discharge. A 2021 study found that zero patients with severe frailty who required CPR survived until a year after hospital discharge. And those with pre-existing frailty who beat the odds and survive are often unable to return home, suffer new cognitive impairment, and can no longer do the activities that previously mattered most to them. For Damar Hamlin, an elite athlete, post-resuscitation recovery is a formidable but hopefully winnable battle. Many of us are far less well-equipped.

What do people with privilege and resources tend to do as they age? We can look to the very recent deaths of three people in their nineties as a reference: Queen Elizabeth II, Barbara Walters, and Pope Benedict XVI. These individuals had first-rate medical care at their fingertips. Yet none of them opted for intensive care, and certainly not for cardiopulmonary resuscitation. Any hands laid on them at the end of life were only to provide comfort. “More” is not always “better.”

The standard of care for a sudden cardiac arrest is to initiate CPR unless a person has an advance directive stating that they do not wish for it. Older Black Americans are far less likely than their white counterparts to have advance directives in place for a myriad of reasons, including socioeconomic disparities and the historical and ongoing failures of our broken and bias-riddled health care system. Advance directives tend to be a marker of social connectedness; ample time and resources; medical literacy; in effect, they are a marker of privilege. People who don’t have them may go on to experience medical trauma that they would never have wanted if they had had the opportunity to have a discussion and voice a preference. We can do better.

As we take a collective moment to consider picking up the skills of CPR, let’s also pause to think about how those skills ought to be deployed and how to create a society where we pursue equity in both the way we rescue and the way we connect with people as they near the end of their lives. Alongside committing to CPR training and widespread defibrillator availability, we should commit on an individual level to having important conversations with those we love about how much they would be willing to endure if they were to become sick. More broadly, we should think as a society about how to ensure that all people who suffer unexpected cardiac arrest, regardless of race, sex, or other human variables, receive timely resuscitation and a fair chance of survival. And conversely, we ought to think about how to equitably approach care near the end of life to ensure that people with advanced age or frailty can access care that aligns with their preferences and upholds their dignity, including protection from the hazards of CPR if they so choose.

As we continue to follow Damar Hamlin’s story and pray for his recovery, perhaps we can make it more than a moment to promote chest compressions; this is important but too simple. Perhaps as more of us learn to use the tool of CPR, we can collectively lean into the work of making sure it is used wisely and equitably on the broader playing fields of our communities.

Carolyn Boscia is an internal medicine physician.