Quality of Life After Cardiopulmonary Resuscitation

clinical investigations in critical care Quality of Life After Cardiopulmonary Resuscitation* Dinis Reis Miranda , M .D.

Objectives: This study evaluates the influence of Cardiopulmonary Resuscitation (CPR) on the components of quality of life (QOL) of patients aft er discharge from the hospital. Design: Extracted from a prospective national survey on Dutch intensive car e units (lCU s). Setting: Thirty-six lCUs of both university and nonuniversity hospitals, spread throughout the country. Methods: For a period of 6 months, 9,803 consecutive lCU admissions entered the stud y. Outcome in connection with in-hospital CPR was analyzed by comparing the CPR group (n=477) with a standardized control group without CPR (n=500). Interventions: Activities of daily living were registered at the time of hospital admission. A record was kept of each patient for demographics, severity of illness , length of stay, dail y use of manpower and ICU technology, and mortality. Six months after hospital discharge, the QOL of 69 patients in both th e CPR and control groups was measured with the Sickness Impact Profile (SIP). Results: CPR was performed in 4.8 percent of the patients, mainly from the general ward. These patients were older, had a higher severity of illness, and a higher daily consumption of nursing resources. The QOL did not correlate with severity of illness on admission, rdiopulm ona ry resuscitation (C PR) became a Cacommon m edical procedure afte r th e introduc-

tion of ext ernal cardiac massage in 1960.1 The longand short-te r m aspects of the outcome of CPR have been studied on a number of occasions, as has th e environmental setting (in or out of hospital) in which th e procedure wa s applied. From the literature on th e subject, it appears that up to 90 percent of th e patients who have undergone CPR may not sur vive up to th e moment of th eir discharge from hospital.P!" The information about the quality of life (QOL) of those who survived CPR after circulatory arrest is, how*From the Intensive Car e Division, Department of Surgery , University Hospital of Groningen, Groningen, the Netherla nds. Supported by grant TA 87-34 from the Dutch Ministr y of Health and by the Foundation for Research on Int ensive Care in Europe (FRICE). Manu script received May 3. 1993; revision acce pted February 18, 1994. Reprint requests: Dr. Miranda , Dept. of Surgery, Univ. Hasp. Graningen , PO Box 30.001, Groningen , 9700 RB Netherlands

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length of stay, or consumption of resources in the ICU . On the whole, the SIP scores of both CPR and control groups did not differ much: 11.7 vs 10.7, and circulatory arrest did not appear to impair the self-sufficiency in the study group significantly in comparison with the controls. An increased dysfunction was found in the CPR group of patients concerning their work and their psychosocial functioning. Conclusion : Patients who have recovered from a circulatory arrest after CPR resuscitation find their capacity for resuming work diminished after discharge from the hospital, while they seem to experience a postponed negative effect on their mental functioning, especially the functions connected with the awareness of their environment. (Chest 1994; 106:524-30) ADL=activities of daily living; APACHE=Acute Physiology and Chronic Health Evaluation; CPR=cardiopulmonary resus citation; DICS=Dutch intensive care study; LOS=length of stay; QOL=quality of life; SIP=Sickncss Impact Profile; TISS=Therapeutic Intervention Scoring System

Key words: cardiopulmonar y resuscitation; intensive care; qualit y of life; sickness impact profile ever, scarce and usually restricted to subjective observations in the margin of studies that have for their object th e survival after CPR . In studying QOL in 41 survivors from a group of 294 patients who underw ent CPR in the hospital , Bedell et al 8 used three diff erent instruments for measuring: memory , depression , and activities of daily living (ADL). It appeared that 38 patients were mentally intact 6 months after hospital discharge , while they had been severely depressed at th e moment of th eir discharge from the hospital, and that a significant impairment of the physical ADL could be observed in many of th em (measured as " reti re m ent" and "homebound"). The mean depression scor e had significantly improved 6 months after hospital discharge and was only slightly higher than that of a control group of 3 ,992 individuals of th e community population . Yet this circumstantial study do es not provide substantial information enough to Quality of Life After CPR (Dinis Miranda)

Table I-SIP Scor es* Category Physical dim ension Body care and movement Mobility Ambulation Overall physical dim ension Psychosocial dimension Social interactions Alertness behavior Emotional behavior Comm unication Overall psychosocial dimension Independent categories Sleep/ rest House management Work Recreation/pastime Eatin g Total SIP

CPR-QOL Group n=69

DICS n= 3,517

QOL Control Group n= 69

9.1 ± 14.8 13.3±20.6 13.8± 17.8 ILl ± 15.7

5.6 ± 11.4t 8.2 ± 14.71 9.1 ± 13.01 7.0± I l.ll

7.5 ± 11.6 1O.8± 15.4 13.4 ±14·11 9.5 ± 1l .7

1O.3 ± 13.3 8.9 ± 16.8 1O.8± 17.8 5.8 ± 11.3 9.2± 11.4

7.6 ± 11.6§ 1O.8±19.9 7.7± 14.9 3.8 ± 1O.0 7.1± 1O.6

9.4 ± 12.3 11.2 ± 20.5 10.5±18.8 5.9 ± 12.0 9.3 ± 12.7

12.4 ± 13.4 18.9 ± 23.9 30.3±33.1 18.4± 20.4 3.3 ±6.1 11.7±11.9

1O.3±14.0 14.7±18.7 21.6 ±31.2§ 16.4±20.1 2.6±5.7 8.5 ± 9.5 1

13.4±17.1 17.3 ± 18.2 20.5± 31.2§ 21.0 ± 21.4 2.7 ±5.2 1O.7± 10.3

*The signs on the DICS group refer to significant differences to the CPR group; on the control group, the first (ambulation) refers to the CPR group and the second (work) to the DICS group. Ip < O.OOI. lp< O.OI. §p<0 .05. circ ula tion was restor ed . Loss of consciousness was not included lead to a meaningful und erstanding of the diff erin th e defin ition of cardiac arrest , becau se of th e impossibilit y of ences in th e structure of QOL after circulator y arrest its bein g uniformly docum ent ed under int ensive ca re cond itions. and CPR . Pati en ts with out-of- hosp ita l ca rdiac arres t were not included . So far to our knowl edge, no investigation has been Of eac h of the 477 pati ents of th e CP R grou p, th e available data conce rn ing th e patient charac te ristics- de mog ra phics, sever ity of conducted that compares th e QOL of pati ents who illness, diagnosis, pr evious health sta tus, fun ctional sta tus before underwent CPR with th e QOL of pati ents with comhospit alizati on, use of the lC U fac ilities (length of stay , manparable cha racteristics for whom no C PR was repow er , and techn ology), and ou tcome (mortality and QO L) for a quired . This study was cond ucted to address this period of 6 months afte r disc ha rge from th e hospit al- wer e sepquestion. ara te ly pooled for ana lysis. Mort ality in the hospit al was collected from the hospit al record s. After hospital d ischar ge, informa tion M ETHODS about mort alit y was collected from th e fam ily physicia n of each pati ent. Afte r the necessar y information had been obtained, and Source of Data afte r a phone ca ll to get th e pati ent's informed consent, a QOL qu estionn air e was mail ed that could be self-ad m inistered . BeTh e data wer e extracted from a pro spectiv e study on the cause of budget constraints, the re was no follow-up of th e pati en ts organization of Dutch int en sive care units (ICUs) , wh ich took who did not return the qu estionn air e. In a lim ited num ber of plac e from Januar y 1990 to Jun e 1992 at 36 ICUs of both pati ent s, outcome was aga in measur ed 2 yea rs later. univ er sity an d nonuniver sity hospit als thro ughout th e country , Con trol Groups f or Studyi ng Out com e: As out com e m ay be representing 21 percent (317 bed s) of the total Dut ch intensive care ca paci ty . Fro m the IC Us in th e study , 28 were multidiscidep endent on pa tien t characteristics like age or clinical condition, pati ent s who ma tched the pati ent cha rac te ristics of th e C PR plin ar y (genera l), 5 were surgical, and 3 we re med ical. Although no coronar y ca re units were incl uded , five ge neral IC Us func group in age, severity of illness, required work load , and length of tioned also as such. stay in th e IC U, but not in the need for CP R, were rand oml y seDuring th e first 6 mon ths of 1990,13,000 consecutive pati ent s lect ed for the outco me studies : (1) CPR control gro up-this gro up ad m itte d to the ICUs entered the study. After disch ar ge from the was composed of 500 pati ents ran doml y extrac te d from DI CS; (2) hospital, 6,247 patients were eligible for pa r ticipa tion in th e QOL QOL contro l gr oup -in 69 patient s of th e C PR gro up (CPR-Q OL group ) QOL was m easur ed . To this end, 69 pati ents wer e substudy , of whom 3,655 patients (58.5 percent) completed the ra ndomly extra cted from the CPR control group of 500 pati en ts, qu estionn air es. A full rep ort in Dut ch is obta inable from th e in ord er to compare th em for QOL (QO L-control group ). Foundation for Resear ch on Int ensiv e Care in Eur ope.'! Oth er Thi s study is a partia l analysis of DICS, as approve d by th e publicat ions are in pr eparation. ethica l committees of th e hospitals invol ved . Patient s Instrum ents Used Study Group: Th e stud y group consiste d of a selection of pa Sever it y of illness and prev ious healt h sta tus we re measur ed tients fro m th e da ta base of the Du tch intens ive care study (DICS) with th e Acute Ph ysiology and Chronic Health Eva lua tion of all patients in the IC U wh o have rece ived C PR after cardiac (APAC H E 11);12 dail y workload with th e Th erap eutic Int er venarrest. Ca rdiac arrest was pr ospecti vely defined as the sudde n tion Scoring Syste m (T ISS);13 dia gnoses wer e recorded in accorcessation of circ ulation, requiring heart massage (other th an sindance wit h th e list of diagnoses proposed by Knaus et al.14 gle chest com pression), with or with out defibrill ation , until CHEST I 106 I 2 I AUGUS T, 1994

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Th e previous fun ct ional status of the pati ents was evaluated by measuring the AD L,15 assessing the ph ysical activity conce rn ing six fun cti ons: body ca re, d ressing, toileting, mobility, control of sphincte rs, and eating . Th e observ ed han dicap is exp re ssed in seven ca tego ries: from A= no handicap , to G = ha nd ica p in all fun ct ions. Th e quality of life afte r discharge was me asur ed with th e Sickness Impa ct Pro file (SIP),16 wh ich is a multid im en sion al and cumulati ve healt h ind ex, consisting of a list of 136 qu estions, divided int o 12 ca teg ories (T able 1). Three of th ese catego rie s (am bula tion, mobi lity, and bod y ca re ) ca n be agg regated int o the Ph ysical Dimen sion; the ca tegor ies of "social int eractions," "alertness be ha vior," "emotiona l beh avior," and "commu nica tion " ca n be agg regated into the Psych osocial Dim en sion; whil e the othe r five, sleep and rest, ea ti ng, work , hom e managem ent , and recr eatio n a nd pastim es are ind ep endent cat egori es. Each category conce rns one spec ific area of th e dail y ac livity , the answer to each q uestion des cribing the (d ys)func tion conce rn ing one daily act ivit y. Th e sim ple and compre he nsive q uestionn air e can be com plete d with the help of an inte rvie wer or ca n be self-adm inlster cd. !" To tal and partial scores can be comp uted , and the resu ltant dy sfunction is given as a per cen tage of th e sum of the weight s of the a nswered qu estions, di vided by the sum of all fac tor weights under analysis. Th e qu estionn aire is availab le in Dutch and has been validated.l" Becau se of the nat ur e of the index, SIP ca n be adm inister ed only to pa tie nts wh o ar e more th an 18 year s old.

Table 2-Patient Characteristics

Age, yr Male/ female,* % APACHE score LOSt T1SS

CPR Group n=69

DICS n=9,803

64 ±1 9 64/ 36 20.1 ± 8.6 5.5 ±9.9 29.3± 11.9

57 ±21 60/40 11.4± 6.6 2.9 ± 6.2 25.2 ± 11.6

*Not Significantly different. [M edi an: CPR group=2 .0; DICS=1.0.

of all CPRs occurred during the first 5 days ; 95 .6 percent had occurred by the 14th day.

Patient Characteristics

There were 9,803 patients in the database of DICS and in possession of the requisite information who participat ed in the study .

The characteristics of th e patients who underw ent CPR were significantly different from the rest of the Dutch ICU population (Table 2). Th e mean age of the patients with CPR was higher, and they also had a higher APACH E II, a higher length of stay (LOS) and a higher mean daily consum ption of manpower (TISS score). Whereas 67 percent of the patients in the Dutch study (DICS) had been admitted from the operating theat er or the recovery room , the higher percentage of th ose requiring CPR had been admitted from the general ward (36.1 perc ent) . The primary diagnosis of th e CPR group at admission in th e ICU was related to dysfunction of the cardiovascular system in 283 pati ents (59.3 percent) , as opposed to a 46 perc ent incidenc e of the patients in DICS. Nin et y-nine patients of the "cardiovascular subgroup" in the CPR group wer e admitted im mediately after a cardiac arrest, 34 had unstable angina pectoris, 34 had coronary surg er y, 20 had congestive heart failure , 20 had rhythm disturbances, and 14 had cardiogenic shock. The incid ence of diagno ses in the CPR group, oth er than cardiovascul ar , was similar to the gene ral distribution of diagnoses in DICS . However, a stepwise multivariate logistic regression anal ysis has shown that the three most frequent cardiovascular diagnoses-acute m yocardial infar ction, rhythm disturbances and postcoronary surgery- were abl e to predict only 10.3 percent of the observed CPRs and that the odds ratio of cardiovascular/ noncardiovascular diagnosis associated with CPR was not different from 1.

Cardiopulmonary Resu scita tion.

Outcome of Patients Who Had Undergone CPR

Cardiopulmonary resuscitation (CPR ) was performed in 477 of th ese patients (4.8 percent), 21 of them receiving CPR twic e during their stay in the IC U and one three tim es. Three hundred fifty-eight of the CPR s were performed on the day of admission to the IC U, 37 on the second da y, 19 on the third day, 7 on th e fourth , and 10 on the fifth day ; 90.4 percent

Mortality: Two hundred fifty-three patients in the CPR group died in the IC U, 181 on the day of CPR , whil e 37 patients died in the hospital after discharge from the ICU (Fi g 1). Mortalit y valu es in th e DICS wer e, resp ectively, 8.1 perc ent for death in the IC U and 4.2 percent for death in hospital. The mortality in the ICU is mu ch higher in the CPR group-around

Statistical Analysis To define two d isproportion at e stra tified groups of pati ents (CP R cont rol a nd QOL-cont rol) , th e random selection was processed from th e com plete list of all the cases in the defined populati on. T he two other stra tified grou ps in thi s study, CP R an d CPR-Q OL, result ed from th e clinical out com e of the patienl s in the origina l Dut ch inlensive ca re popul ation. Regarding th e varia bles involved, the d iffer ent gro ups of pati ents wer e com pa red as described in th e text. Th e compa rison of sample mean s betw een continuo us variabl es was analyzed by mean s of the Stude nt's two sam ple t tesl and th e anal ysis of var iance (ANOYA). Nominal variables were analyze d by th e X2 test. Univa riate regression an alysis was used to estab lish significant interaction be twee n var iabl es, while stepwise multivari at e logistic regression an alysis was used-when ever ind ica ted and when signi ficance was obse rved- to iden tif y the vari abl es with a significa nt " inde pe ndent" rela tion with binary dep enden t var iables. Explorativ e fac tor a na lysis was used to study th e score struc ture of QOL in the pat ients, both those with and those without ca rdiopulmona ry resuscit ation. A speci fic pro gram (Statistical Pack age for Social Sciences, SPSS-X, ver sion 3.0) at th e Univ er sity of Gro ninge n was used for the sta tistica l ca lculati ons a nd random izations. RESULTS

526

Quality of Life After CPR (Dinis Miranda)

/

Died in ICU n=253 (53%)

Cardiopulmonary resuscitations n=477 (4.8%)

<,

Survived leu n=224 (47%)

1

Died in hospital n=37 (7.8%)

....

Died within 6 months n=23 (4.8%)

Lost to follow-up n=24 (5%)

,0.21

D;d not n=71 (15%) FIG URE

Mailed survey n=140 (29%)

n=69 (14%)

1. Flow charl of Cf' R grou p.

50 pe rce nt in almost all diagnostic ca tego ries and consistently high er than in th e C PH control group (17 percent ). After discharge from th e IC U, th e mortality rat es in both groups show less div ergen ce: 16 perc ent (CP H group) vs 10 percent (CPR control gro up ) in hospital, and were not diff er ent 6 months aft er d ischarge: 12 perc ent vs 18 percent. Tw ent yfour survivors in th e CPR gro up (14.6 percent ) and 42 in th e CPR control gr oup (13.7 percent ) could not be tr aced . The patients in the CPH gro up who died wer e not older th an those who survived . Th eir mean LOS in th e IC U was shorter than in th e CPH control group: 4.6±9.5, medi an=1 vs 7.2± 10.2, med ian=3 da ys; p= .OOO; their mean APAC HE II score on th e admission da y was high er : 23.0± 8.1 vs 17.2±8.0; p= .OOO ; and the y had a higher dail y consumption of man powe r resources: mean TISS30.7 ± 12.2 vs27.8 ± 11.5; p< .005. Quality of Life: One hundred fort y pati ent s in the CPH group who wer e still aliv e 6 months aft er dischar ge wer e asked to com plete a SIP questionna ire, 69 of whom responded (CPR-QOL group) (Fig 1). Ther e was no follow-up of the patients who did not return the questionnaire. No diff erenc es wer e found , however , between th e characteristics of th e 69 re spondent and th e 71 nonrespondent patient s as regards age , LOS, mean APACHE II score , TI SS

score , and the medical and sur gical categories (eme rgency or electi ve). In order to evaluate the quality of life of the CPH-QOL group of pati ents, a compara ble QOL control group of 69 patient s was randoml y extrac ted from th e population of DICS (see Methods). The charac te ristics of the pati ents in th e QOL control group for mean age , male to female rat io, mean APACHE II score, mean TlSS , and mean LOS , were not diff er ent from those of the CPR-QOL group. Forty pati ents in th e QOL control group had a "card iovascular " diagnosis vs 46 in th e CPR-QOL group . Fourteen patient s in each group acc ounted for the most fr equent cardiovascular diagnose: postcoron ar y sur gery. The remaining distribution of card iovascular diagno ses was similar in both groups, exce pt for seven patients in th e CPR-QOL group who had been ad mitted on account of a cardiac arrest that had occurred prior to th e day of ad mission. The struc ture of th e SIP score of both the C PR-QOL and the QOL control groups is presented in Table 1, together wit h th at of th e pati ent s in DICS. No correlation was found between th e SIP score and age , APACHE II score, LOS , TISS, or th e technology used in th e l CU for th e pr evention an d / or tr eatment of respiratory and/or hemodynamic failure (mec hanical ventilation , inotropic drugs , and Swan -Ganz cathe te r). A ctivities of Daily L iving (ADL): As indicated in " methods," ADL was scored for each pati ent on ad mission to th e IC U. Sixty-th ree pati ents in each group (CPR-QOL and QOL control) had no handicap at th e time of their admission to the IC U (score = A). Th e ADL score of th e rem aining 12 patients was eq ually distributed in both groups- up to score G (2 patients). A multivariate regr ession analysis has shown that th e pr evious existence of handicap in both groups, as measur ed by ADL on ad m ission , could explain 9 percent of the cases with Phy sical Dimension valu es abov e the mean (p < 0.002) and 5 perc ent of th e cases with a total SIP score abov e th e mean (p < 0.004). SlP scor e: Th e tot al SIP score of th e C PR group (range : 0/42.4) is higher th an in DICS (range: 0/62.4; p
527

diff erent for th e inde pe nde nt ca tego ry " work ," th e diff er ence being det erm ined by th e fact that 27 patients in the CPR-QOL group were incapabl e of resuming work vs 19 in the QOL con trol gro up. Th e answers to th e othe r eight q uestions in thi s categ ory showed no sign ificant d ifference be tween th e two groups. Th e SIP scores of th e 14 "post-coro na ry surgery " pati ent s in eac h gro up were not d ifferent: respectively,9.7 ± 11.2 (CPR-QO L) an d 7.4 ± 8.8 (QOL control). Th e mean SIP score of eight patients with CPR af ter ac ute myocardial infarcti on was 6.2 ± 5.8, and seve n pat ients admitted to th e ICU afte r ca rd iac arrest occ ur ring prior to ad mission scored 11.1 ± 8.6. Of th e 69 patients in th e CPR-QOL group, 12 randoml y selec ted patients answe red a second questionnaire , mailed 2 yea rs aft er th eir discharge from the hospital. The mean SIP score of th e 12 patients was 8.2 ± 10.3 (range: 0/35), and not differ ent from the mean SIP score of th e same 12 patients 18 months ea rlier (9.9 ± 12.3; ran ge: 0/36). In all ca tego ries, th e seco nd SIP score was lower th an the first, altho ugh not statistica lly diff er ent, except for th e categ ories of "alertness behav ior" (7.6 ± 20.6, ran ge 0/ 72 , vs 5.5 ± 9.3 , range 0/ 28) and "eating" (3.1 ±5.7, range 0/ 19, vs 0.9± 2.2, range 0/ 6). Th e observed increase of th e handicap of "aler tn ess behavior" was ca used by a twofold incr ease in the incide nce of d ysfun ct ion conc erning three dail y activities: "small accide nts," " reac tion to th e environment," an d " orien tation ." Th e increase of th e handica p of "eating," too, was caused by a twofold increase in th e inciden ce of dysfun ction concern ing three dail y ac tiv ities: "amo unt of ing ested food ," "d iet," and " fee d ing him /herself ." With a view of obt aining a better int erpretation of the SIP scores observed in th e CPR-QO L and th e QOL control groups, an explora tive factor analysis of the SIP structure was perform ed in both groups. It should be rem ember ed th ough th at th e fac tor an alysis is a multivari abl e an alysis with an explora tive value only, em ploye d solely in th e analysis of th e interrelati onshi ps amo ng a set of variables.l'' Altho ugh the SIP scores depict ed in Tabl e 1 were sta tistically not di fferent exce pt for th e ca tego ry " work," th e factor anal ysis showed a differ ent SIP structure between th e two gro ups: an undefine d dimension (factor 1) in th e CPR-QOL gro up agg regates the grea ter pa rt of th e physical and psychosocial cat egories , together wit h a d im ension (factor 2) th at aggregates th e ca tegories "alertness beh avior ," "communicati on," an d "work." Th e SIP in the QOL contr ol group had a struc ture similar to that in th e origina l instrurn ent.l" Psychosocial Dim ension (fact or 1), Ph ysical Dimensi on (factor 2), and five inde pendent 528

ca tego ries. DISClJSSIO •

Altho ugh mort ality in connec tion with CPR has been fr equently rep ort ed , little informat ion is available abo ut the QOL of th ese patien ts after th eir d ischa rge from th e hospita l. As th e analyses in th e available stud ies are mor eover exclusively concerned with pati ent s on who m CPR was performed , no ac cou nt has been tak en of the fact th at , ind ependently of th e occ ur rence of C PR, age and seve rity of illness ar e also relevant fa ctors of outcome.ll ,l 2,14 In th is study, th e surviva l rat e and th e QOL aft er disch ar ge in connec tion with the occ urrence of CPR were ana lyzed in a stratified group of 477 patients as part of a Dutch national int en sive ca re sur vey. Th e sur vival rat e aft er CPR (39 percent ) was high er th an th at q uoted in th e liter ature. This diff er en ce may hav e few explanations. Fi rst , all patients who had CPR and who died in th e hospit al before reach ing th e IC U were obviously not considered; seco nd , th e study included a very selec ted group of pati ent s after ca rdiac arrest occ ur ring in th e lC U and its neighborhood (ope rating th eat er ) to whom , expe ctedly, CPR was immed iat ely and appropri at ely ad m inistere d ; th ird , pati ents who had out-of-hospital C PR were not included . The aim of th e study was the com parison of outcome of patient s who underwen t CPR, with th e outcome of pa tie nts who d id not bu t who had been sta nda rd ized for age and severit y of illness: two di spr oporti onat e stratified gro ups of patients (CPR contro l and QOL control groups) were ra ndom ly ge nera ted fr om th e na tiona l sur vey, as described in Methods. These groups are th er efore not representative of th e population fr om which th ey have been derived . Considering th e fact that th e discriminative pow er of th e available scor es for measuring severity of illness for pr edicting outcome is rather un stable for sma ll groups of patients, th e stan da rdization of th e groups in the study concern ing severity of illness was strength ened by addi ng two oth er varia bles to th e APAC HE II score: required workload (TlSS) and LOS in th e IC U. Th e associa tion of these two variab les with seve ri ty of illness is well known . Th eir incl usion was m ad e under the assumption th at th e associa tion of the three variables is stable in th e stu d y, in th e view th at th e dat a ha ve been sim ultaneously genera ted in a defined number of lC Us und er sim ilar man agerial an d env ironme ntal cir cumstan ces. Yet, although th e two gro ups of pati ents were com parabl e to th e possible exte nt, th e fact that one group of pati ents required CPR may sugg est that th e pati ents in thi s gro up were sicker th an th ose in th e other group. Quality of Life After CPR (Dinis Miranda)

To measur e QOL , a number of instruments have been devised , th e majority of which , however, concern the valuation of ph ysical dimen sions of the dail y activities, providing no inf orm ati on a bout the int ellectual function and th e psychosocial ac tivities of the studi ed subj ects .i" In exploring th e after effects of circul atory arrest and involved tr an sient cerebral hypoxia , th e valuation of th e afore me ntioned functions is necessary. Th e SIP seem ed the most suitable instrument to use, besides th e fact that th e recognition of its gene ral value in measuring QOL is growing and that it is available in a validated Dutch version. As th e collect ed data did not provide any comparabl e information about the exact duration of circulatory arrest in many patients , the cases involving out-of-hospital cardiac arrest and CPR were not included in th e analysis on th e assumption that, in this way, th e majority of outli ers were excluded. This is th e reason that this study is solely conc erned with th e investigation of th e influenc e of circ ulatory arrest upon the components of QOL, and that its result s do not represent th e outcome of th ose cases in which th e circu latory arrest ma y ha ve lasted longer before appropriate assistance was available. A select group of 69 pati ent s who had undergone C PR participated in th e QOL study : th ey survi ved C l' H, th ey surv ived hospit al discharge and , after all , th ey were capable and willin g to answe r the survey. Th at only 50 percent of th e 140 eligible patients responde d to th e SIP qu estionn air e is not uncommon in this type of survey. It is not unlikely, however , that a diff er ent profile of d ysfunction would be found in th e i1 nonresponders to the sur vey. Yet , the aim of th e study was to explore diff er ent patterns rather th an th e extension of QOL dysfunction. The fact that the mean SIP score of the Cl'H group was higher than that of the DICS population was mainly due to a Significantly higher handicap wher e the categories of the Ph ysical Dimension (Table I) were concerned . Th ese diff er enc es, which might hav e been erroneously ascribed to the CPR event, disappeared when the SIP score of th e CPR group was compared with th e SIP score of a group of patients who , except for CPR, had been standardized to th e pati ent characteri stics of the Cf'H gr oup. Thi s observation suggests that , in gene ral, th e occurrence of CPR does not increase the overall ph ysical hand icap of surv ivors, and it reinforc es th e knowl edge th at the QOL bet ween diff erent groups can be compared only if the groups are comparable, at least in age . Th e ph ysical handicap th at was regist er ed at a later date , mor eover, ma y be partially explained by the fun ctional status of the pati ents before hospital ad mission. In a study comparing QOL in a group of 424 patients 6 months aft er circulatory arrest, with th e QOL on a control

group of 495 enrollers in a pr epaid health organization , Bergner et al 20 found that th e SIP score of three fifth s of the patients who had undergone CPR was higher than that of th e controls. Since they did not observ e any loss of self-sufficien cy concerning th e ADL , their findings bear out our observations. A significantly diminished capacity for resuming work was found among th e pati ents who had undergone CPR. Bergner et aF o reported similarly, noting , howe ver , that the score on th e " work" category was associated with th e pr evious work status of th e patients , being generally worse for those patients who were unemployed at the tim e of th e cardiac arrest . Th e effects of circulatory arrest on th e intellectual function of patients, too , is obviously a matter of concern. From the study of Bed ell et al ,8 it appears that 38 of 41 CPR survivors wer e mentally intact 6 months after discharge from the hospital. They showed , however, severe mental depression. When it was measured again , 6 months later, the depression had improved . Bergner et al 20 hav e found a worsening of memory function in 36 percent of th e patients after CPR , which was associated with th e SIP score on th e "alertness behavior" category. We noted a similar handicap in our study when , during a second measure me nt of SIP in 12 of th e pat ients who had und ergone CPR 2 years aft er discharge , we noticed a diminishing personal int er est in th e environme nt and an increasing sense of disorientation. An explanation of th ese obser vations may be provided by the explorative factor analysis of th e SIP score structure, already 6 months after discharge: although the QOL control group follows the gen eral structure described by th e authors of the instrument.l" the factor analysis identified a different structure for the CPR-QOL group, in which "alertness behavior" was int erestingly separated from th e oth er categories composing th e psychosocial dimension, seemingly bearing out th e inventoried observations. Patients who have recov ered from circulatory arrest in an ICU environme nt aft er CPR find their capacity for resuming work diminished after discharge from th e hospital and expe rie nce a postponed negative effect on their mental functioning , especially th ose functions that ar e relat ed to th eir awaren ess of the envi ronme nt. R EFERENCES

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Quality of Life After CPR (Dinis Miranda)