Days after his heart stopped and he collapsed motionless on a football field, Damar Hamlin is reportedly awake, moving his hands and feet and communicating. This young man could have died, but he is alive and appears to be recovering — a testament to the power of high-quality cardiopulmonary resuscitation, or CPR.
There is still much that remains unknown about Mr. Hamlin’s condition and his recovery moving forward. But what is clear is that this type of catastrophic event, a sudden cardiac arrest in a young athlete, is precisely what CPR was designed for.
For many doctors working in hospitals, CPR has become one of the necessary motions that we go through toward the end of a patient’s life, but when used on an otherwise healthy person with a sudden reversible injury, as was apparently the case for Mr. Hamlin, this emergency procedure is remarkable. It is simple enough to be accessible to a layperson with minimal training. And when performed promptly and correctly, it can mean the difference between life and death.
For Mr. Hamlin, the quick initiation of chest compressions and shocks restored his heartbeat and allowed him the chance to return to normal life. Yet CPR is a procedure like any other, and its benefit is all about context. Which is how the same lifesaving protocols that were used on that football field have become a ritual of dying in the intensive care unit.
A colleague recently shared with me a landmark publication from the 1960s on the outcomes of resuscitation. The authors — pioneers of the techniques that have become modern-day CPR — wrote about their early successes but cautioned that this procedure was to be used judiciously on patients within the hospital. “Not all dying patients should have cardiopulmonary resuscitation attempted,” they wrote. “The patient should not be in the terminal stages of a malignant or other chronic disease, and there should be some possibility of a return to a functional existence.” But this is not how it has come to pass.
Instead, doctors meet in a family conference room. Inside the unit, the patient is already intubated and on dialysis, blood pressure supported by multiple intravenous medications. We explain the medical realities to the family and then we talk about whether their loved ones would want CPR if their hearts stopped. Sometimes the family says no. But sometimes, even when resuscitation will not bring their loved ones back to an acceptable quality of life, they insist. This is what their loved ones would want, they say, perhaps imagining an outcome like Mr. Hamlin’s. They would want us to have done “everything.”
Of course, the fact that CPR works on a healthy person who collapses on a football field does not mean that the same procedure will be effective for someone who has been in the intensive care unit for weeks. But in these charged moments, when families simply want nothing more than for their loved ones to be OK, it is often impossible for them to acknowledge the limitations of what we can offer. Sometimes the kinder act on our part is to acquiesce, knowing that we are also caring for this family and that the moment of crisis is rarely the time to correct long-held misconceptions about the benefit of our interventions.
Perhaps it is more useful, then, to think about these realities now. To understand how misleading it is to extrapolate from a case like Mr. Hamlin’s to the act of performing — and in these situations it is, in a way, performative — CPR on a critically ill patient in the intensive care unit.
First, there is the question of what precipitated the cardiac arrest. In a young athlete, sudden cardiac arrest is more likely because of a dangerous electrical rhythm in an otherwise healthy heart that leaves the organ unable to effectively pump blood through the body. In these cases, chest compressions will circulate blood — and bring oxygen to the brain and other vital organs — until a defibrillator is available to shock the heart back to its regular rhythm.
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 cancause 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