Restarting hearts

Crash course

How long should doctors spend trying to restart a stopped heart?

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As a nurse for 32 years, I have seen and participated in more "Code Blues" than I can count. Research continues to help medicine and nursing come up with standard interventions that improve the lives of people. It is difficult to standardize things (in my opinions) like how long to continue because there are many variables: heath status before the cardiac arrest occurred, what medications were already in the body and then added during the code, age is a factor but not in and of itself (for example, I have taken care of a 91 year old who was healthier and on no medications than the 50 year old in the next room). It comes down to every professional doing their best within their situation (equipment, medications, staff). These kind of studies are helpful in gathering data to help determine 'good practice' and standards. Evidenced based practice is something medicine and nursing is doing even more deliberately to establish 'gold standards' of care. Thank you for sharing this information and article. I look forward to reading the original one in The Lancet. Linda O'Dell, RN, MSN

Like I was saying...

The fact that "evidence-based medicine" is even a subject of discussion tells you the hollowness in medicine's pretension of being some kind of "hard" science.

The medicine field needs a big fat dose of honesty and humility.


I have to point out that the article you quote regards in-hospital cardiac arrests, which is a different "can of worms" from cardiac arrests that occur on the street. Many in-hospital arrests are the last act of a gradual deterioration of the patient's condition, and the resuscitation efforts are half-hearted attempts to "do something", if there is no standing "do not resuscitate" order. Other in-hospital arrests would be unexpected, in patients who are "too good to die", and in such cases the attempt to resuscitate the patient would be extensive, mobilizing all the available resources and expertise, time-consuming, and more likely to succeed, because the patient was more or less stable when some treatable factor caused cardiac arrest. I hope that this article will be discussed and dissected by experts in CPR, and will not make us thump away on a deceased patient for an extra 10 minutes just to save our reputations.

Defibrillators do not restart stopped hearts. They in fact stop hearts which are working pathologically, in the hope that they will beat more normally after they restart themselves.


"But plenty of medicine has only a thin base in scientifically reviewed evidence, meaning that the opinions, judgments and prejudices of individual doctors often determine how treatment is given."

How disheartening!


Very useful paper.Shows: (1)good scientific training; (2)good modern technology and (3)persistence can save lives. Too often, the "system" either discourages or does not expedite these. Eugene Sherry MD


Sometimes we halt at a door that may just be the one to let us out of a labyrinth .Generally longer resuscitation correlates with higher chances of return of spontaneous circulation but this also depends on weither it was a witnessed arrest and also on the availability of advance life support systems which becomes a factor in resource constraint settings,for instance in developing countries.
Am of the opinion that we resuscitate for longer & save more lives. One opinion is that you continue resuscitating until you are exhausted but again this put to question, the fitness of the resuscitator(s)

Sani Umar, Kano Nigeria.

Moran ya Simba

I used to work in the cardiology ward as a physician and had to make such decisions myself. It is true that there are no firm guidelines. My "philosophy", if one can call it that, was that it was better to save one who could be saved and risk producing 5 "vegetables" than to let all 6 die. I am not sure that this is the right approach because none that had been in cardiac arrest for more than 5 minutes, ever became "good" to my knowledge, in our ward. So I warmly welcome this study!


The doctors try their best. When they give up, they tell you, “I have done my best now you pray as I cannot do anymore” I find this sentence very soothing as the Dr, removes himself done the danger zone and he has tries all he could. Not all can do all in few hours that the heart or any organ in our body tries to fight the external virus, external illness that we brought knowingly or unknowingly. I hope the doctor has done his part so have the sisters assisting him I would love to go out a happy man leaving the Dr and the patient as is No more tussle with the doctor as I may need him again. In my life I have learnt that it is useless to change accountant, doctors and lawyers as they know all they have to about you. Please do not go elsewhere shopping for cheap labour I thank you Firozali A.Mulla DBA

msherratt in reply to guest-iosnaoa

"31 198 of 64 339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6—21) compared with 20 min (14—30) for non-survivors. ......"
There is a confusing use of language. Differentiating groups would be simpler if attempted resuscitation-successful resuscitation and failed resuscitation were used. A further concern is pooling data across hospitals. It would have been far more interesting to have performed 'within center' analysis, on the assumption that variation in practice would thus be minimised. The paper is interesting and maybe detailed statistics and raw data are published in the full text. As an attendee at intern grade at many attempted resuscitations and a witness to several grim neurological outcomes, I'd like to suggest that challenging current practice is healthy, but changes in practice need to be based on much better evidence. Michael Sherratt


This is ripe for commentary; I'm actually surprised that there aren't more comments already posted.

As a cardiologist, I (unfortunately) routinely run codes. Some of these are on otherwise healthy patients who have acutely decompensated, and have a substrate which predisposes them to a better outcome, even if the resuscitative effort is prolonged. Naturally, I would give these patients every possible effort before stopping resuscitative measures. On the other hand, there are (again, unfortunately) many patients whose cardiac arrest is the culmination of a long, steady decline. Think months to years, not minutes to hours. These are the patients who may not necessarily benefit from resuscitation to begin with; however, in accordance with the patient's or the family's wishes, I am obligated to try. As one can imagine, my decision to terminate CPR generally comes earlier in these cases. This is not because my decisions are swayed by a value judgement on my part (that is, I'm not simply starting the effort then stopping short, just so I can say "we tried; this patient shouldn't have been coded to begin with") This is based on the fact that resuscitation is most likely to be successful within the first minutes of cardiopulmonary arrest; the chances of a favorable outcome drop precipitously with each passing minute, even if one leaves out any consideration of neurologic function.
So.. patients who are judged to be sicker at baseline and less likely to recover from an arrest, are going to receive an abridged resuscitative effort. Patients who are more likely to recover and who have more potential years of productive life ahead of them, are going to have a prolonged effort. Therefore, the favorable outcomes seen with a "willingness to try" may simply reflect a patient population that is intrinsically more likely to have a favorable outcome.

The obvious response to what I've just said is, these are decisions made by physicians at the bedside about individual patients. This study looks at the CPR efforts and outcomes stratified by HOSPITALS, which should negate the patient-to-patient variability I'm pointing out. This suggests that practice patterns affect outcomes in these cases. However, as a physician at a university medical center, my patient population as a whole is more ill than the patient population at outlying community hospitals. As a tertiary referral center, we routinely accept the patients who need highly specialized care. The patient population, then, is less likely to recover from cardiopulmonary arrest. And the resuscitative effort, on average, is going to be shorter, because the patients who experience an arrest are more likely to have a poor chance of recovery.

Am I convinced that prolonged CPR simply doesn't work? Not at all. If the effort is carried on, there is a chance, however small, of recovery. If CPR is stopped, the chance of recovery immediately goes to zero. I think this paper raises an interesting point, and I think that this is probably the only real-world way to study the effects of CPR duration on survival. However, it is important to keep the potential confounders in mind.


I searched the web for a more detailed summary of the study and was unable to find very much. I do not subscribe to the Lancet so I guess I am out of luck.

I have questions like "Are the extra 12% of 'survivors' being discharged from their hospital to their home with the expectation of survival, or are they being discharged to a Hospice awaiting death?" In other words, are the extra 12% appearing in the 'discharge' stats but in reality are just delaying final death a few days at home or a Hospice? It could be that this study is an example of bad-research. Or it could be exposing another revenue stream for the hospital. I can't tell. We will have to wait and see.

Secondly, most people believe that the medical procedures they receive have been subjected to rigorous scientific and medical analysis. Procedures which result in benefits are continued, and those that are questionable or of little benefit are discontinued. This is not uniformly true! Even procedures shown by this kind of research to be of no value are billable by the doctor and the hospital and there is no standardized mechanism to review this kind of care, at least not in the U.S. The U.K. does review procedures and the NHS does not pay for such care.

I saw an interview on TV where a notable medical doctor who had invented a common "procedure" was read a scientific review of his procedure by a prestigious researcher. The conclusion was that the procedure had no greater benefit than a much cheaper and less risky procedure. The Dr. professed to be "surprised" but said he would continue to teach his procedure! He refused to elaborate to the interviewer. $$$?

The U.S. needs to implement a review process similar to the NHS to expose those procedures which are of little or no benefit, and determine if and when a procedure is called for. There is no reason to enrich doctors and hospitals without question. And yes, I am a registered Republican.

Have a nice day!

MySetDancer in reply to

Defibs may be used in conjunction with specific medications and CPR to restart a stopped heart. But you are correct in that most of the time a defib by itself is not used to start a stopped heart. Search the medical sites for detailed info.


A heart attack can happen by clogging of the coronary arteries or by interference with the Purkinje fibres circuit of the heart electrical system. The heart has its own muscular structure and not just in vertebrates, is it unique in an organism. Molluscs also have this as well as other animals.

The heart functions on a self contained electrical system which includes the electrolytic condition of the blood. The blood acts as a capacitor for this electrical circuit. When an infarction takes place a portion of the heart tissue dies. It can be replaced over time but this takes years. My father had a heart attack in 1982, he lived around the corner from a hospital, after two electroshocks he came back to life. He had a second heart attack but fortunately knew what was happening and got to a clinic, The third infarction was fatal. This from a lifelong habit of smoking.

MySetDancer in reply to msherratt

See your local Lancet for full details. The Economist does not publish, as far as I know, full study details in any of their articles. I searched the web and was unable to find much more study info.


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