We saw this work in Mr. Hamlin’s case. Chest compressions began promptly, minimizing the time his brain went without oxygen. A defibrillator was present and used appropriately, likely returning his heart to a normal rhythm. This process is referred to as the “chain of survival.” If any step is missing or even delayed, someone who could have survived could die or survive only to be left with significant brain damage.
Sadly, in cardiac arrests that occur outside the hospital, like this one, bystander CPR is only performed about one-third of the time. It’s less likely to be received by racial or ethnic minorities. This matters — if CPR is started immediately, the chances of survival can double or even triple — and is a powerful argument for ongoing education by national and local organizations to train laypeople, even at young ages, in the simple principles of resuscitation and advocate better access to defibrillators. Had Mr. Hamlin collapsed on the street rather than the football field, his outcome likely would have been different.
But in the intensive care unit the question is not whether we have the infrastructure to perform high-quality CPR, it is whether we should use it. In contrast to the arrhythmia or heart attacks that can cause an arrest outside the hospital in a previously healthy individual, these stories are different. Many of these patients are in the final stages of a lethal illness before their hearts stop. We see codes in patients already on ventilators with profound respiratory failure, advanced cancer or sepsis whose blood pressure continues to fall despite escalating doses of medications to raise it.
In this population of intubated patients in the I.C.U., just 6 percent who have an arrest and are resuscitated will make it out of the hospital with little or no brain disability. For the vast majority, CPR becomes one more act that must be done before death, one more medicalized ritual, rather than a potentially lifesaving intervention with a chance of real success.
Decades ago, patients were put under do-not-resuscitate orders by their doctors — often unbeknown to them. This decision was recorded with a note or a coded symbol on the chart, visible to the medical staff but not to the patients themselves. In other cases, when they believed CPR to be futile but a family insisted, doctors would plan to run a “slow code,” omitting the most aggressive steps.
Perhaps we have gone too far in the other direction. We regularly perform the act of resuscitation against our better judgment, in a way that we do not for other procedures. And when there is no reasonable hope of any meaningful benefit but we offer CPR as a choice anyway, we may do our patients and their families a disservice. Just as it is essential to improve knowledge and training about bystander CPR so that we give others like Mr. Hamlin the best chance of survival and recovery, so too is it essential to recognize what CPR cannot do.
When Mr. Hamlin woke, still intubated, he is said to have asked in writing which team had won the football game on Monday. As if he had simply risen from a long slumber and wanted to know what he had missed. In response, his doctors told him that he had won the game of life.