Patients participate in decisions about their care today as never before. As the physician–patient relationship has evolved into a collaborative one, patients are expected to digest and evaluate complex information, often at a time of great emotional stress. This is particularly true with respect to decisions about the end of life.

Patients have few sources from which to learn about illness and death. Acute illness — and, in particular, terminal illness — is for many people no longer part of everyday life. Therefore, images in the media strongly shape the public's beliefs about medicine, illness, and death.21 The portrayal of CPR and death on three popular television programs is misleading in a number of ways.

First, these three television programs give a misleading impression about the kind of people most commonly given CPR. On television, children, teenagers, and young adults accounted for 65 percent of the patients given CPR. Of the total number of deaths on the programs, 83 percent were of nonelderly patients. In fact, cardiac arrest is much more common in the elderly than in children or young adults.

Second, cardiac arrest on television was often due to acute injury, the result of gunshot wounds, motor vehicle accidents, or near-drowning; only 28 percent of the patients had primary cardiac arrests. In real life, 75 to 95 percent of arrests result from underlying cardiac disease.8,10,19

Third, CPR succeeded more frequently on television than in the real world as reflected in the medical literature. On all three shows combined, 75 percent of the patients were alive immediately after their cardiac arrests, and 67 percent appeared to survive in the long term. On Rescue 911, which focuses on the successes of emergency services, the survival rate after CPR was 100 percent. Of the patients on ER, 65 percent survived the initial arrest; three of these patients died before discharge from the hospital. On Chicago Hope, 64 percent of the patients given CPR initially survived cardiac arrest, and 36 percent survived to discharge.

Comparing these survival rates with those in the medical literature is problematic, since the patients seen on television differ dramatically from those described in the literature with respect to age, underlying illness, and the cause of cardiac arrest. Nevertheless, we would argue that the survival rates in the medical literature are the figures that ought to be given the most weight by patients and families making decisions about the use of CPR.

Rates of long-term survival after cardiac arrest as reported in the medical literature vary from 2 percent to 30 percent for arrests outside a hospital, and from 6.5 percent to 15 percent for arrests that take place inside a hospital.6-19 For average elderly patients, the rate of long-term survival after cardiac arrest outside a hospital is probably no better than 5 percent. For arrests due to trauma, the reported survival rates vary from 0 to 30 percent.22-25 Clearly, the rates on television are significantly higher than even the most favorable data reported in the literature.

Finally, on television, the outcome of CPR was generally portrayed as either full recovery or death. The only case of disability was in the young man who had moderate dysarthria after his inhalation of butane and a cleaning agent. If CPR were a benign, risk-free procedure that offered a good hope of long-term survival in the face of otherwise certain death, few people would ever choose to have medical personnel withhold resuscitation. But controversy surrounds the use of CPR precisely because the procedure can lead to prolonged suffering, severe neurologic damage, or an undignified death.26 In 97 episodes of these medical dramas and reenactments, such outcomes were never portrayed. CPR on television is given primarily to people suffering from acute illness or injury; the possible outcomes are dichotomized into full recovery or immediate death. By avoiding the portrayal of the full range of possible outcomes of CPR, these programs skirt the complicated ethical issues that physicians, patients, and families need to consider.

In a subtle way, the misrepresentation of CPR on television shows undermines trust in data and fosters trust in miracles. In the stories retold on Rescue 911, physicians often predict poor outcomes for patients, while family members voice their hope and, in the end, their joy in the “miracle” of their loved ones' recovery. We acknowledge that this drama produces good television, as evidenced by the large viewing audiences. However, these exceptional cases may encourage the public to disregard the advice of physicians and hope that such a miracle will occur for them as well. Faith is central to our ability to maintain hope in difficult situations and often is an important adjunct to the therapy physicians offer. Belief in miracles, however, can lead to decisions that harm patients. The portrayal of miracles as relatively common events can undermine trust in doctors and data.

Misrepresentations of CPR on television may lead patients to generalize their impressions to CPR in real life. For example, an 85-year-old woman with metastatic breast cancer may believe that CPR can work as well in her situation as it does for the 23-year-old trauma victim on television. Physicians discussing decisions about the end of life with patients and families should be aware that the public has many sources of information about CPR, some of them misleading. To help patients and families make informed decisions, doctors should encourage patients to discuss their impressions of CPR and its chances of success. We should clarify misperceptions, provide actual data on outcomes, and address specifically the differences between CPR as seen on television and CPR as it is experienced by real patients.

There are limitations to our study. First, we looked at only three television programs. We chose these programs because they enjoy enormous popularity and focus on medicine, but the occasional portrayals of CPR elsewhere may be more realistic. Second, this analysis rests on the assumption that the public does not distinguish fact from fiction. Unfortunately, however, an important part of the attraction of these television programs is their realism.27 In many respects, these programs accurately portray the medical environment. People want to go behind the scenes to see true stories of medicine, and modern television works hard to satisfy this curiosity. Because these shows appear realistic in many respects, the line between fact and fiction is blurred.

What should our response be? Given the media's extraordinary influence, we could hope that the producers of television programs might recognize a civic responsibility to be more accurate. This may not happen, however. The primary goal of these television series is to entertain, a goal served by the high drama and the promise of hope all three shows offer.

Given this reality, physicians need to recognize and acknowledge the images the media present as we help patients and families make informed decisions about the use of CPR. During discussions about the use of CPR, we should inquire about our patients' perceptions of survival after CPR, specifically address the images of CPR on television, and present quantitative data about possible outcomes to our patients, when appropriate. With these efforts, physicians, patients, and families will be able to make better-informed decisions about these difficult issues.