Introduction

According to management guidelines, cardiopulmonary resuscitation (CPR) is indicated in all cases of cardiorespiratory arrest, unless there are clinical signs of irreversible death such as rigor mortis, lividity, or decapitation, the existence of advance directives, or DNR orders, or if the cardiopulmonary arrest occurs in a situation in which the safety of the personnel performing the resuscitation maneuvers is not guaranteed (1).

According to the American Heart Society, by 2020, the survival rate at hospital discharge for 209,000 people who suffered in-hospital cardiac arrest was 25.8%. In addition, between 20% and 60% of survivors suffered permanent cognitive deficits, reflected in impaired memory, attention, and executive functions, secondary to cerebral hypoxia. Less than 5% of the survivors reached a cognitive level close to the premorbid state one month after resuscitation. (2).

It has been seen that the general population, including physicians, tends to overestimate this survival rate and perceive the post-event recovery to be higher than the actual figures, which directly influences the desire to be subjected at some point to CPR maneuvers and apply them to patients. Such misperceptions are caused by a lack of adequate information, an overestimation of the curative capacity of medicine, and the influence of the media, including movies, which play a key role in this regard. Studies by Harris and Willoughby (3) and Diem et al. (4) have shown that television series such as Casualty, ER, Holby City, and Grey's Anatomy overestimate in their episodes the survival rate of CPR maneuvers (42% to 77%), which has thus conditioned viewers' perception of CPR survival and, possibly, their desire to undergo them.

Several authors have reported that knowing the actual data on survival to hospital discharge and the functionality of those who survive makes many unwilling to receive CPR maneuvers. (5).

As far as the medical profession is concerned, factors such as the fear of lawsuits, the perception of professional failure, the difficulty of establishing conversations with the patient and his or her family, and the lack of adequate information and training on the reality of CPR condition the actions and willingness of physicians to perform CPR maneuvers on others and to allow themselves to perform them if necessary (6).

In an uncontrolled randomized observation by the authors, it was perceived that there is a lack of information among medical students on this subject since a significant discrepancy was found between the perception of CPR survival at hospital discharge and the actual rates.

The main objectives of this study were to describe and compare the personal perceptions of undergraduate medical students at the Pontificia Universidad Javeriana (Bogotá campus) regarding the survival rate at hospital discharge after in-hospital CPR, as well as their willingness to undergo such maneuvers. In addition, we sought to evaluate whether knowing the real information about the survival rate at hospital discharge after in-hospital CPR maneuvers generated a change in the decision of the participants to undergo or not undergo these maneuvers.

Materials and methods

A cross-sectional observational study was designed through a voluntary and anonymous face-to-face survey. The survey population consisted of undergraduate medical students over 18 years of age who were studying between the first and tenth semesters. The survey was structured through Google Forms (see appendix). The survey consisted of an initial consent form for participation and was divided into three parts. The first collected demographic data on the respondents. The second part asked what they believed to be the survival rate at hospital discharge after in-hospital CPR (in percentage ranges of 10% to 10%) and whether they would agree to undergo CPR maneuvers in the event of in-hospital cardiac arrest. Subsequently, respondents were provided with the actual information about survival rates after in-hospital CPR, information with which they were to proceed to the third and final section, where they were asked if, after learning the actual survival rates, they would still agree with which CPR maneuvers were best for them.

Results

Out of 877 undergraduate medical students from the first to tenth semesters, a total of 692 (78.9% of the target population) participated. The number of students per semester who responded to the survey can be seen in Table 1. Of the total respondents, 468 (67.2 %) were female, 223 (32.2 %) were male, and 1 (0.1 %) was of unspecified gender. The age range was between 18 and 31 years, with a mean of 20 years.

As the survey asked about survival grouped in percentage ranges (see appendix), to have a better understanding of the results, and taking into account that survival is less than 30%, it was decided to group these results into three groups: less than 30% (low survival); 31%-60% (medium survival), and 61%-100% (high survival), according to table 2. Out of the total number of students surveyed, 39% considered the survival rate after in-hospital CPR to be low, 37% considered it to be medium, and 24% considered it to be high (Table 2). For 61% of all respondents, survival to hospital discharge is greater than 30%.

Out of the students in the basic medical sciences semesters (first to fifth), 34% considered the survival rate after in-hospital CPR to be low, and 66% thought it was greater than 30%. On the other hand, 55% of the students in the clinical application semesters (sixth to tenth) considered it to be higher than 30%.

Regarding whether participants would perform CPR in the hypothetical case of in-hospital cardiopulmonary arrest, 95.5% of all students surveyed would do so, while 4.5% would not. After providing the respondents with information on the actual success rate of CPR, they were asked again whether or not they would undergo these maneuvers. Of those surveyed, 75.3% said they would, while 24.7% said they would not. The desire to receive CPR went from 95.5 % to 75.3 % when knowing the in-hospital survival from CPR with a p-value < 0.0001, when using McNemar's test for difference in proportions of matched samples. In this case, the same individual before and after (Figure 1).

Discussion

Although the in-hospital CPR survival rates reported by the American Heart Society and the European Resuscitation Council (2,7) are less than 30%, some studies have shown that people greatly overestimate the likelihood of a possible positive outcome (8,9), suggesting that there is an obvious discrepancy between the actual success rate and the perception of the general population, including physicians. Very optimistic perceptions of the success of CPR would probably lead to the general population often demanding it, and physicians applying it indiscriminately, even though it is a costly, morbid, often unsuccessful, and often unindicated endeavor (1,10).

The results obtained are consistent with these studies (11-14) and show that more than 60% of medical students overestimate the success of CPR, considering it to be greater than 30%, which is far from the real figures. This overestimation is more evident in students of basic medical sciences semesters, and this is similar to the perception of the general population, which can be attributed to the lack of clinical practice and the lack of appropriation of concepts. Surprisingly, more than 55% of students with more exposure to clinical practice had an unrealistic perception of CPR success, which may lead them to omit critical information about actual CPR success rates when they graduate, thus affecting their medical judgment and introducing their own bias into shared decision making with patients.

Within the undergraduate medical curriculum, it is worth noting that CPR classes begin in the first semester. In that order of ideas, all respondents had already received this knowledge, although it is not clear whether they were provided with the basics of CPR ethics and actual survival rates in this cathedra. It should be noted that, generally, basic or advanced life support courses or classes focus on how to save a life or perform CPR maneuvers, but the actual survival statistics are omitted (15).

In addition, although medical students are considered a population in training with access to updated and verified knowledge, they are not exempt from the information transmitted by the media (3,4), which tends to overestimate the survival rates of CPR maneuvers. Additional factors that would condition students' responses, such as lack of exposure to CPR maneuvers or follow-up of cardiorespiratory arrest cases, as well as personal beliefs with social or religious foundations, should be taken into account.

Unrealistic expectations of CPR success would have a direct effect on a patient's expectation of personal survival and preference for CPR. The personal desire to receive CPR in the event of cardiac arrest may change when individuals receive adequate information. In a study by Murphy et al. (16), a group of people was initially surveyed about their preference to receive CPR in the event of cardiac arrest, then educated about their actual survival probability after CPR, and finally asked again about their desire to receive CPR in the event of cardiac arrest. The percentage change before and after learning the actual rates was found to be 19% (16). This value is similar to that reported in this study, where the percentage of change was 20.2%. This is evident and statistically significant, so the probability that it is due to chance is very low. This means that knowing the real survival rate of CPR maneuvers changes the willingness to accept them, which would also lead to changes in the physician's desire to administer these maneuvers to his or her patients.

The present study had some limitations, such as the fact that it was conducted at a single institution and the sample did not include students in the last two semesters, who have had greater clinical exposure, which limits the generalizability of the findings.

Conclusions

This study highlights the need to introduce and intensify education in clinical ethics in medical schools, and to initiate conversations on CPR in these courses from the first semester, educating about the real rates of in-hospital and out-of-hospital survival, as well as the clinical and ethical indications for CPR, given that there is a significant lack of this information. A rupture has been detected between technique and ethics in the clinical practice of CPR, a necessary integration to offer patients adequate, integral medical care.

This study should be taken into account by other faculties in the country and in other countries, to question and rethink, if necessary, the approach given to these topics throughout the curriculum established by the institutions, to train ethically responsible health professionals.

References

Author notes

^aCorrespondence author: rezk.gabriel@javeriana.edu.co

Additional information

How to cite: Arbeláez Gutiérrez P, Rezk Schuler GS, Gempeler FE, Moreno DC. Medical school students’ perception of PCR survival rate: a descriptive study. Univ Med. 2023;64(1). https://doi.org/10.11144/Javeriana.umed64-1.rced

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