October is Sudden #Cardiac #Arrest Awareness month. Today the current system to document your wishes fails. When you have seconds to minutes to have your life saved, would you want someone to guess with your care? Learn more mideohealth.com

Honor the Advance Directive—or not? jimdemaine.substack.com/p/ho… Should your health advocate sometimes change things given a new situation?

91.5 percent of people who have a cardiac arrest outside a hospital die or end up neurologically devastated. A technique that gets survival to around 30 percent exists, and it is still mostly confined to academic centers. Jon Marinaro, a critical care physician, has spent his career on it. The technique is ECMO applied during CPR, within an hour of the arrest. #ThePodcastbyKevinMD CPR came along in 1956. From then until about 2000, pushing on the chest was the only thing anyone in the world could do for a person in cardiac arrest. Around 2000, a paper on putting defibrillators in airports showed that a shock delivered right after the arrest pushes neurologically intact survival as high as 35 to 40 percent. Everyone who didn't respond to the shock got CPR, got shocked again, and died. That is the group ECMO is for. The mechanism most people never hear: "75 to 78 percent of all cardiac arrests die because their brain doesn't get saved. It's not because their heart doesn't come back." The first 5 to 10 minutes are about the heart. After two or three shocks with no response, the job becomes saving the brain, and for the people who don't respond to the shocks the mortality drops off substantially. ECMO is bypass done percutaneously. A large cannula in the femoral vein drains blood, a pump pressurizes it, an oxygenator pulls off CO2 and adds oxygen, and it returns through the femoral artery. Centers doing this during CPR report around 30 percent neurologically intact survival, in patients who already failed the defibrillator and who are typically getting on 30 to 60 minutes after the arrest. Marinaro has put people on at an hour and 16 minutes who survived. One hypothermic arrest got 3 hours of CPR and walked out. The clock, which is the part worth saving: No-flow time over 5 minutes, meaning nobody on the chest, and the patient is not a candidate. Bystanders lose those minutes because the person looks like they're seizing or is still gasping, which are normal post-arrest things the body does. Once CPR starts, 55 more minutes. An hour total from collapse to being on the machine. Marinaro calls it the final 60. A team in the Netherlands runs it from a helicopter and has the collapse-to-flow time down to 40 minutes. Paris cannulates people on the floor of the Metro. Marinaro's group outfitted an ambulance. The barrier, he argues, is not skill. ER and critical care doctors put in central lines. These are bigger central lines. The arterial cannula in a paper he is about to publish is 13 French, the size of a dialysis catheter. The venous one is about 25 French, the size of his index finger. The barrier is the device. The pumps are expensive, the disposables run $14,000 to $15,000, and the machines have a lot of buttons and things to zero, which scares people off. For the first couple of years his ambulance ran a hand crank. A firefighter turned it. It worked fine. The American Heart Association has moved ECMO above amiodarone for refractory VT and VF arrest, a 2A indication. One San Diego system trained 150 ER doctors and made it the standard of care for anyone who arrests in its area. His ask to every shift-working ER, ICU, and trauma doctor: "Take the time, go to an ECMO class, learn how to be an ECMO cannulator. It's not hard. It's just getting over a little hump." Listen to the full conversation on The Podcast by KevinMD. Link in the replies. How far is the nearest hospital to you that can do this?

320,000 people between the ages of 20 and 64 die unexpectedly in this country every year. 60 percent of adults have no advance directive. We counsel patients on smoking and exercise and tend not to raise this at all. That argument comes from Joseph Pepe, a retired internist who moved into administration, ran a 330-bed hospital as its CEO, sat on hospital boards and on the board of an insurance company, was a patient with a life-threatening illness twice, and then became the caretaker for a wife whose illness was called terminal. His position is that the estate planning packet belongs in the same category as the exercise talk and the smoking talk. He is explicit that we tend not to do it because a visit already has too much in it, and equally explicit that this is not a reason. Sometimes it takes more than one visit, and he says that is fine. The vocabulary is where most of us go fuzzy, so here it is cleanly. An advance directive, or living will, records what the patient would want. It is wishes, not orders. A POLST or a DNR is an order. Different instrument. And it does not travel the same way across state lines, so a form that governs in one state may not govern in another. A health care proxy, or medical power of attorney, names who speaks when the patient cannot. A durable power of attorney covers money. It is a separate document from the medical one, and people conflate the two constantly. A HIPAA release is the one everybody forgets. Without it, the family cannot obtain records or talk to the treating physicians, which means they are being asked to make informed decisions with no information. A revocable trust handles assets and distribution and keeps the family out of probate. Pepe puts the threshold at a net worth over $250,000. He also has a practical fix for the conversation itself. A family at a bedside will answer for themselves without ever noticing they switched subjects, which is why a daughter says I want this while sitting in a room where the question was about her father. Ask them instead what they think he would have wanted, and Pepe says the answer arrives almost immediately. On how to raise it inside a 15- to 20-minute visit, his opener puts the stakes on somebody else. You're healthy now, you're stable now, and anything can happen, and this is for your loved one's sake. He says patients get receptive the moment it stops being about them. His ethical rule, from three decades of bedsides and boardrooms: "If you do what's right by the patient, you'll always be right." Listen to the full conversation on The Podcast by KevinMD. Link in the replies. What is the one document your patients are most likely to be missing when you actually need it? #AdvanceDirectives #ThePodcastbyKevinMD