The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation

Low Rates of Survival Seen in Orthopedic Patients Receiving In-Hospital Cardiopulmonary Resuscitation

INTRODUCTION

Despite awareness of overall poor survival rates following cardiopulmonary resuscitation (CPR), some orthopedic patients with significant comorbidities continue to have inappropriate resuscitation plans. Furthermore, in certain injury groups such as patients with hip fractures, survival outcome data are very limited; current discussions regarding resuscitation plans may be inaccurate. This study assesses survival in orthopedic patients following CPR, to inform decision-making between physicians, surgeons, and patients.

METHODS

A dual center, retrospective cohort study was performed analyzing all orthopedic admissions that received CPR over a 25-month period, with a minimum of 1 year follow-up. National Cardiac Arrest Audit data, "mortality and morbidity" meeting records, National Hip Fracture Databases, and electronic notes were analyzed. Survival duration was measured, alongside reason for admission, location CPR occurred, and initial rhythm encountered.

RESULTS

Thirty-two patients received CPR over the 25-month period (median age: 83; range: 30-96). Three (9%) of 32 patients survived to discharge. Only 1 of the 26 patients older than 65 years survived to discharge. Fifteen (47%) of 32 had hip fractures, where 4 (27%) of 15 of this group survived 24 hours; none survived to discharge. When recorded, 22 (92%) of 24 initially had a nonshockable rhythm.

DISCUSSION

Cardiopulmonary resuscitation was conceptualized as a treatment for reversible cardiopulmonary causes. When used in trauma and orthopedic patients, especially older and/or hip fracture patients, it seldom led to hospital discharge. Different admission practices such as "front door" orthogeriatric reviews may explain the contrast in usage of CPR between the hospitals.

CONCLUSION

Survival rates following CPR were very low, with it proving specifically ineffective in hip fracture patients. Although every decision about resuscitation should be patient centered and individualized, this study will allow clinicians to be more realistic about outcomes from CPR, particularly in the hip fracture group.

Specialist Physician Approaches to Discussing Cardiopulmonary Resuscitation for Frail Older Adults: A Qualitative Study

Background: Despite the impact and importance of end-of-life discussions, little is known about how physicians discuss cardiopulmonary resuscitation (CPR) with patients and their families. The necessary components for successful communication about CPR are poorly understood and an established framework to structure these conversations is lacking. Here, we were motivated to understand how physicians approach resuscitation planning with families when older patients have limited life expectancy and a high burden of illness. Method: Qualitative analysis was conducted of semi-structured interviews of 28 physicians of varying medical sub-specialties in a tertiary care hospital. Results: Most physicians explored the surrogates’ goals and values, but few provided explicit information about the patients’ overall health status or expected long-term health outcome related to CPR and underlying illnesses. Conclusion: There is considerable heterogeneity in physicians’ approaches to CPR discussions. The principle of autonomy is dominant with less emphasis on providing adequate information for effective decision-making.

Discrepancy between treatment goals documentation by oncologists and their understanding among cancer patients under active treatment with chemotherapy

OBJECTIVE/BACKGROUND

Discussion of treatment goals between oncologists and patients is challenging. Patients frequently misunderstand goals of therapy. There are several methods to document goals of chemotherapy, however, and are frequently not incorporated into patient charts.

METHODS/DESIGN

Cancer patients receiving their first cycle of chemotherapy were interviewed. Patients' recall of discussions with their oncologist regarding therapy intent was assessed and compared to documentation. An adjusted McNemar's test was utilised. A one-sample proportion test was used to evaluate whether the overall observed rate of discordance was significantly different from the proposed 33% rate; a rate posited as a threshold too high in the clinical sense.

RESULTS

Two hundred and seven eligible patients were interviewed. Oncologist identified treatment goals were not documented in 24.6% of cases and had to be excluded. There was not a significant difference in the directionality of discordance present. Inter-rater agreement between patient and oncologist was found to be adequate (κ = 0.64). The overall rate of discordance (17.29%) was found to be significantly less than the proposed acceptable level of 33% (p < 0.01). Upon univariable analysis, age, gender, marital and employment status were not found to be associated with discordance.

CONCLUSIONS

Discordance between treatment goals documentation and their understanding exists, indicating continued miscommunication between the patient and oncologist.

Discordance between Physician and the General Public Perceptions of Prognostic Disclosure to Children with Serious Illness: a Korean Nationwide Study

BACKGROUND

It is difficult to decide whether to inform the child of the incurable illness. We investigated attitudes of the general population and physicians toward prognosis disclosure to children and associated factors in Korea.

METHODS

Physicians working in one of 13 university hospitals or the National Cancer Center and members of the general public responded to the questionnaire. The questionnaire consisted of the age appropriate for informing children about the prognosis and the reason why children should not be informed. This survey was conducted as part of research to identify perceptions of physicians and general public on the end-of-life care in Korea.

RESULTS

A total of 928 physicians and 1,241 members of the general public in Korea completed the questionnaire. Whereas 92.7% of physicians said that children should be informed of their incurable illness, only 50.7% of the general population agreed. Physicians were also more likely to think that younger children should know about their poor prognosis compared with the general population. Physicians who opposed incurable illness disclosure suggested that children might not understand the situation, whereas the general public was primarily concerned that disclosure would exacerbate the disease. Physicians who were women or religious were more likely to want to inform children of their poor prognosis. In the general population, gender, education, comorbidity, and caregiver experience were related to attitude toward poor prognosis disclosure to children.

CONCLUSION

Our findings indicate that physicians and the general public in Korea differ in their perceptions about informing children of poor prognosis.

Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision

BACKGROUND

As the "do not resuscitate" (DNR) discussion involves communication, this study explored (1) the effects of a title that included "allow natural death", and of information contents and outcomes of the decision; and (2) the information needs and consideration of the DNR decision, and benefits and barriers of the DNR discussion.

METHODS

Healthy adults (n = 524) were presented with a scenario with different titles, information contents, and outcomes, and they rated the probability of a DNR decision. A questionnaire including information needs, consideration of the decision, and benefits and barriers of DNR discussion was also used.

RESULTS

There was a significantly higher probability of signing the DNR order when the title included "allow natural death" (t = - 4.51, p < 0.001), when comprehensive information was provided (F = 60.64, p < 0.001), and when there were worse outcomes (F = 292.16, p < 0.001). Common information needs included remaining life period and the prognosis. Common barriers were the families' worries and uncertainty about future physical changes.

CONCLUSION

The title, information contents, and outcomes may influence the DNR decisions. Health-care providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.

Protocol and Fidelity Monitoring Plan for Four Supports. A Multicenter Trial of an Intervention to Support Surrogate Decision Makers in Intensive Care Units

Individuals acting as surrogate decision makers for critically ill patients frequently struggle in this role and experience high levels of long-term psychological distress. Prior interventions designed to improve the sharing of information by the clinical team with surrogate decision makers have demonstrated little effect on surrogates' outcomes or clinical decisions. In this report, we describe the study protocol and corresponding intervention fidelity monitoring plan for a multicenter randomized clinical trial testing the impact of a multifaceted surrogate support intervention (Four Supports) on surrogates' psychological distress, the quality of decisions about goals of care, and healthcare use. We will randomize the surrogates of 300 incapacitated critically ill patients at high risk of death and/or severe long-term functional impairment to receive the Four Supports intervention or an education control. The Four Supports intervention adds to the intensive care unit (ICU) team a trained interventionist (family support specialist) who delivers four types of protocolized support-emotional support; communication support; decisional support; and, if indicated, anticipatory grief support-to surrogates through daily interactions during the ICU stay. The primary outcome is surrogates' symptoms of anxiety and depression at 6-month follow-up, measured with the Hospital Anxiety and Depression Scale. Prespecified secondary outcome measures are the Patient Perception of Patient Centeredness Scale (modified for use with surrogates) and Impact of Event Scale scores at 3- and 6-month follow-up, respectively, together with ICU and hospital lengths of stay and total hospital cost among decedents. The fidelity monitoring plan entails establishing and measuring adherence to the intervention using multiple measurement methods, including daily checklists and coding of audiorecorded encounters. This approach to intervention fidelity may benefit others designing and testing behavioral interventions in the ICU setting. Clinical trial registered with www.clinicaltrials.gov (NCT01982877).

Views of cancer patients regarding cardiopulmonary resuscitation in Greece

Cardiopulmonary resuscitation (CPR) in patients with cancer is an ethical issue of worldwide interest. A questionnaire-based study was carried out in a Greek oncology hospital aiming to explore the attitude of Greek cancer patients towards CPR. Overall, 200 patients (94 male, 106 female) of a mean age of 62.8 years took part in the study. Only 42 (21%) patients indicated that they knew what CPR really involves and only 20 (10%) patients thought that CPR has serious side effects, while the mean estimated in-hospital CPR survival rate to hospital discharge was 56.6% (minimum = 2%, maximum = 99%, standard deviation [SD] = 25.16) and 42.1% (minimum = 0%, maximum = 90%, SD = 24.56%) in case of unselected and cancer patients respectively. Despite their poor knowledge, 177 (88.5%) patients were willing to undergo CPR in case of an in-hospital arrest, 127 (63.5%) thought that they had the right to choose their CPR status and 141 (70.5%) believed that they should be asked about it when they enter the hospital. Most patients (36%) wanted their CPR status to be decided by themselves, their family and their doctor jointly. These findings indicate that specific measures should be applied to clinical practice in order to best manage this ethical issue, and consequently, improve cancer care.

Testing a new form to document 'Goals-of-Care' discussions regarding plans for end-of-life care for patients in an Australian emergency department

OBJECTIVE

There is limited literature to inform the content and format of Goals-of-Care forms, for use by doctors when they are undertaking these important conversations.

METHODS

This was a prospective, qualitative and quantitative study evaluating the utility of a new 'Goals-of-Care' form to doctors in a private, tertiary ED, used from December 2016 to February 2017 at Cabrini, Melbourne. A Goals-of-Care form was designed, incorporating medical aims of therapy and patient values and preferences. Doctors wishing to complete a Not-for-CPR form were also supplied with the trial Goals-of-Care form. Form use, content and patient progress were followed. Doctors completing a form were invited to interview.

RESULTS

Forms were used in 3% of attendances, 120 forms were taken for use and 108 were analysed. The median patient age was 91, 81% were Supportive and Palliative Care Indicators Tool (SPICT) positive and patients had a 48% 6-month mortality. A total of 34 doctors completed the forms, 16 were interviewed (two ED trainees, 11 senior ED doctors and three others). Theme saturation was only achieved for the senior doctors interviewed. Having a Goals-of-Care form was valued by 88% of doctors. The frequency of section use was: Aims-of-Care 91%; Quality-of-Life 75% (the term was polarising); Functional Impairments 35%; and Outcomes of Value 29%. Opinions regarding the ideal content and format varied. Some doctors liked free-text space and others tick-boxes. The median duration of the conversation and documentation was 10 min (interquartile range 6-20 min).

CONCLUSIONS

Having a Goals-of-Care form in emergency medicine is supported; the ideal contents of the form was not determined.

Advance Directives: From the Perspective of the Patient and the Physician

American physicians and patients share some common ground in their perspectives on advance directives. The majority in both groups strongly endorse the use of these documents. Both groups believe it is the physician's responsibility to initiate the discussion about advance directives. However, a gap between the two perspectives can be defined. In end-of-life decision making, physicians balance the ethical principle of patient autonomy with other principles such as appropriate withholding of care in the setting of futility. Patients’ preferences for end-of-life care are most influenced by expected outcomes. Physicians tend to be selective in their indications for initiating a discussion about advance directives, according to clinical factors. In contrast, most patients want to discuss advance directives with their physician under all circumstances.

A video depicting resuscitation did not impact upon patients' decision-making

Background

Previous studies have demonstrated that video of and scripted information about cardiopulmonary resuscitation (CPR) can be deployed during clinician–patient end-of-life discussions. Few studies, however, examine whether video adds to verbal information-sharing. We hypothesized that video augments script-only decision-making.

Methods

Patients aged >65 years admitted to hospital wards were randomized to receive evidence-based information (“script”) vs. script plus video of simulated CPR and intubation. Patients’ decisions registered in the hospital record, by hospital discharge were compared for the two groups.

Results

Fifty script-only intervention patients averaging 77.7 years were compared to 50 script+video patients with a mean age of 74.7 years. Eleven of 50 (22%) in each group declined CPR; and an additional three (script) vs. four (script+video) refused intubation for respiratory failure. There were no differences in sex, self-reported health trajectory, functional limitations, length of stay, or mortality associated with decisions.

Conclusion

The rate at which verbally informed hospitalized elders opted out of resuscitation was not impacted by adding a video depiction of CPR.

Horizontal mixture model for competing risks: a method used in waitlisted renal transplant candidates

When a patient is registered on renal transplant waiting list, she/he expects a clear information on the likelihood of being transplanted. Nevertheless, this event is in competition with death and usual models for competing events are difficult to interpret for non-specialists. We used a horizontal mixture model. Data were extracted from two French dialysis and transplantation registries. The "Ile-de-France" region was used for external validation. The other patients were randomly divided for training and internal validation. Seven variables were associated with decreased long-term probability of transplantation: age over 40 years, comorbidities (diabetes, cardiovascular disease, malignancy), dialysis longer than 1 year before registration and blood groups O or B. We additionally demonstrated longer mean time-to-transplantation for recipients under the age of 50, overweight recipients, recipients with blood group O or B and with pre-transplantation anti-HLA class I or II immunization. Our model can be used to predict the long-term probability of transplantation and the time in dialysis among transplanted patients, two easily interpretable parts. Discriminative capacities were validated on both the internal and external (AUC at 5 years = 0.72, 95% CI from 0.68 to 0.76) validation samples. However, calibration issues were highlighted and illustrated the importance of complete re-estimation of the model for other countries. We illustrated the ease of interpretation of horizontal modelling, which constitutes an alternative to sub-hazard or cause-specific approaches. Nevertheless, it would be useful to test this in practice, for instance by questioning both the physicians and the patients. We believe that this model should also be used in other chronic diseases, for both etiologic and prognostic studies.

Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach

The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.

Informed consent and the aftermath of cardiopulmonary resuscitation: Ethical considerations

BACKGROUND:

Patients often are confronted with the choice to allow cardiopulmonary resuscitation (CPR) should cardiac arrest occur. Typically, informed consent for CPR does not also include detailed discussion about survival rates, possible consequences of survival, and/or potential impacts on functionality post-CPR.

OBJECTIVE:

A lack of communication about these issues between providers and patients/families complicates CPR decision-making and highlights the ethical imperative of practice changes that educate patients and families in those deeper and more detailed ways.

DESIGN:

This review integrates disparate literature on the aftermath of CPR and the ethics implications of CPR decision-making as it relates to and is affected by informed consent and subsequent choices for code status by seriously ill patients and their surrogates/proxies within the hospital setting. Margaret Urban Walker's moral philosophy provides a framework to view informed consent as a practice of responsibility.

ETHICAL CONSIDERATIONS:

Given nurses' communicative skills, ethos of care and advocacy, and expertise in therapeutic relationships, communication around DNAR decision-making might look quite different if institutional norms in education, healthcare, law, and public policy held nurses overtly responsible for informed consent in some greater measure.

FINDINGS:

Analysis from this perspective shows where changes in informed consent practices are needed and where leverage might be exerted to create change in the direction of deeper and more detailed discussions about CPR survival rates and possible consequences of survival.

Challenges in implementing an advance care planning programme in long-term care

BACKGROUND

A high prevalence of cognitive impairment and frailty complicates the feasibility of advance care planning in the long-term-care population. Research aim: To identify challenges in implementing the 'Let Me Decide' advance care planning programme in long-term-care.

RESEARCH DESIGN

This feasibility study had two phases: (1) staff education on advance care planning and (2) structured advance care planning by staff with residents and families. Participants and research context: long-term-care residents in two nursing homes and one community hospital. Ethical considerations: The local research ethics committee granted ethical approval.

FINDINGS

Following implementation, over 50% of all residents had completed some form of end-of-life care plan. Of the 70 residents who died in the post-implementation period, 14% had no care plan, 10% (with capacity) completed an advance care directive and lacking such capacity, 76% had an end-of-life care plan completed for them by the medical team, following discussions with the resident (if able) and family. The considerable logistical challenge of releasing staff for training triggered development of an e-learning programme to facilitate training.

DISCUSSION

The challenges encountered were largely concerned with preserving resident's autonomy, avoiding harm and suboptimal or crisis decision-making, and ensuring residents were treated fairly through optimisation of finite resources.

CONCLUSIONS

Although it may be too late for many long-term-care residents to complete their own advance care directive, the ' Let Me Decide' programme includes a feasible and acceptable option for structured end-of-life care planning for residents with variable capacity to complete an advance care directive, involving discussion with the resident (to the extent they were able) and their family. While end-of-life care planning was time-consuming to deliver, nursing staff were willing to overcome this and take ownership of the programme, once the benefits in improved communication and enhanced peace of mind among all parties involved became apparent in practice.

Cardiopulmonary resuscitation is not addressed in the admitting medical records for the majority of patients who undergo CPR in the hospital

Cardiopulmonary resuscitation (CPR) is routinely performed on patients who develop cardiopulmonary arrest in the hospital. In some situations, it is performed on terminally or critically ill patients where death is predicted to be inevitable despite CPR. Since prior consent is not required for this procedure, CPR may be performed without patient consent or foreknowledge. Many of these patients may not want CPR if the anticipated outcome is reviewed with them.

This study investigated the frequency of occurrence of a CPR discussion at the time of hospital admission for patients who undergo CPR during hospitalization. Results showed that CPR is infrequently addressed in the hospital orders or medical records in patients who undergo CPR during their hospital stay. In addition, the severity of illness at the time of admission does not appear to influence whether physicians discuss CPR with patients and their families.

Korean Nurses’ Attitudes to Good and Bad Death, Life-Sustaining Treatment and Advance Directives

This study was an investigation of which distinctive elements would best describe good and bad death, preferences for life-sustaining treatment, and advance directives. The following elements of a good death were identified by surveying 185 acute-care hospital nurses: comfort, not being a burden to the family, a good relationship with family members, a readiness to die, and a belief in perpetuity. Comfort was regarded as the most important. Distinctive elements of a bad death were: persistent vegetative state, sudden death, pain and agony, dying alone, and being a burden to the family. Of the 185 respondents, 90.8% answered that they did not intend to receive life-sustaining treatment if they suffered from a terminal illness without any chance of recovery; 77.8% revealed positive attitudes toward advance directives. Sixty-seven per cent of the respondents stated that they were willing to discuss their own death and dying; the perception of such discussions differed according to the medical condition ( p = 0.001). The elements of a bad death differed significantly depending on the disease state ( p = 0.003) and on economic status ( p = 0.023).

Preferences For Prolonging Life: A Prospect Theory Approach

Kahneman and Tversky's (1979) Prospect theory was tested as a model of preferences for prolonging life under various hypothetical health statuses. A sample of 384 elderly people living in congregate housing (263 healthy, 131 frail) indicated how long (if at all) they would want to live under each of nine hypothetical health conditions (e.g., limited to bed or chair in a nursing home). Prospect theory, a decision model which takes into account the individual's point of reference, would predict that frail people would view prospective poorer health conditions as more tolerable and express preferences to live longer in worse health than would currently healthy people. In separate analyses of covariance, we evaluated preferences for continued life under four conditions of functional ability, four conditions of cognitive impairment, and three pain conditions—each as a function of participant's current health status (frail vs. healthy). The predicted interaction between frailty and declining prospective health status was obtained. Frail participants expressed preferences for longer life under more compromised health conditions than did healthy participants. The results imply that such preferences are malleable, changing as health deteriorates. They also help explain disparities between proxy decision-makers' and patients' own preferences as expressed in advance directives.

Outcomes of In-Hospital Cardiopulmonary Resuscitation Among Patients With Cancer

OBJECTIVE

To review all episodes where an emergency code was called in a cancer-specialized hospital in Pakistan and to assess survival to discharge among patients who received a cardiopulmonary resuscitation (CPR).

METHODS

We reviewed demographic and clinical data related to all "code blue" calls over 3 years. Multivariate logistic regression analyses were used to test the association of clinical characteristics with the primary outcome of survival to discharge.

RESULTS

A total of 646 code blue calls were included in the analysis. The CPR was performed in 388 (60%) of these calls. For every 20 episodes of CPR among patients with cancer of all ages, only 1 resulted in a patient's survival to discharge, even though in 52.2% episodes there was a return of spontaneous circulation. No association was found between the type of rhythm at initiation of CPR and likelihood of survival to discharge.

CONCLUSIONS

The proportion of patients with advanced cancer surviving to discharge after in-hospital CPR in a low-income country was in line with the reported international experience. Most patients with cancer who received in-hospital CPR did not survive to discharge and did not appear to benefit from resuscitation. Advance directives by patients with cancer limiting aggressive interventions at end of life and proper documentation of these directives will help in provision of care that is humane and consonant with patients' wishes for a dignified death. Patients' early appreciation of the limited benefits of CPR in advanced cancer is likely to help them formulate such advance directives.

Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with serious illness, and their families, state that better communication and decision-making with healthcare providers is a high priority to improve the quality of end-of-life care. Numerous communication tools to assist patients, family members, and clinicians in end-of-life decision-making have been published, but their effectiveness remains unclear.

OBJECTIVES

To determine, amongst adults in ambulatory care settings, the effect of structured communication tools for end-of-life decision-making on completion of advance care planning.

METHODS

We searched for relevant randomized controlled trials (RCTs) or non-randomized intervention studies in MEDLINE, EMBASE, CINAHL, ERIC, and the Cochrane Database of Randomized Controlled Trials from database inception until July 2014. Two reviewers independently screened articles for eligibility, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each of the primary and secondary outcomes.

RESULTS

Sixty-seven studies, including 46 RCTs, were found. The majority evaluated communication tools in older patients (age >50) with no specific medical condition, but many specifically evaluated populations with cancer, lung, heart, neurologic, or renal disease. Most studies compared the use of communication tools against usual care, but several compared the tools to less-intensive advance care planning tools. The use of structured communication tools increased: the frequency of advance care planning discussions/discussions about advance directives (RR 2.31, 95% CI 1.25-4.26, p = 0.007, low quality evidence) and the completion of advance directives (ADs) (RR 1.92, 95% CI 1.43-2.59, p<0.001, low quality evidence); concordance between AD preferences and subsequent medical orders for use or non-use of life supporting treatment (RR 1.19, 95% CI 1.01-1.39, p = 0.028, very low quality evidence, 1 observational study); and concordance between the care desired and care received by patients (RR 1.17, 95% CI 1.05-1.30, p = 0.004, low quality evidence, 2 RCTs).

CONCLUSIONS

The use of structured communication tools may increase the frequency of discussions about and completion of advance directives, and concordance between the care desired and the care received by patients. The use of structured communication tools rather than an ad-hoc approach to end-of-life decision-making should be considered, and the selection and implementation of such tools should be tailored to address local needs and context.

REGISTRATION

PROSPERO CRD42014012913.

Variability in physician prognosis and recommendations after intracerebral hemorrhage

OBJECTIVE

To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score.

METHODS

A written survey with 2 ICH scenarios was completed by practicing neurologists and neurosurgeons. Selected factors were randomly varied (patient older vs middle age, Glasgow Coma Scale [GCS] score 7T vs 11, and presence vs absence of a validated prognostic score). Outcomes included predicted 30-day mortality and recommendations for initial treatment intensity (6-point scale ranging from 1 = comfort only to 6 = full treatment).

RESULTS

A total of 742 physicians were included (mean age 52, 32% neurosurgeons, 17% female). Physician predictions of 30-day mortality varied widely (mean [range] for the 4 possible combinations of age and GCS were 23% [0%-80%], 35% [0%-100%], 48% [0%-100%], and 58% [5%-100%]). Treatment recommendations also varied widely, with responses encompassing the full range of response options for each case. No physician demographic or personality characteristics were associated with treatment recommendations. Providing a prognostic score changed treatment recommendations, and the effect differed across cases. When the prognostic score suggested 0% chance of functional independence (76-year-old with GCS 7T), the likelihood of treatment limitations was increased (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.12-2.33) compared to no prognostic score. Conversely, if the score suggested a 66% chance of independence (63-year-old with GCS 11), treatment limitations were less likely (OR 0.62, 95% CI 0.43-0.88).

CONCLUSIONS

Physicians vary substantially in ICH prognostic estimates and treatment recommendations. This variability could have a profound effect on life and death decision-making and treatment for ICH.

Key stakeholders' perceptions of the acceptability and usefulness of a tablet-based tool to improve communication and shared decision making in ICUs

PURPOSE

Although barriers to shared decision making in intensive care units are well documented, there are currently no easily scaled interventions to overcome these problems. We sought to assess stakeholders' perceptions of the acceptability, usefulness, and design suggestions for a tablet-based tool to support communication and shared decision making in ICUs.

METHODS

We conducted in-depth semi-structured interviews with 58 key stakeholders (30 surrogates and 28 ICU care providers). Interviews explored stakeholders' perceptions about the acceptability of a tablet-based tool to support communication and shared decision making, including the usefulness of modules focused on orienting families to the ICU, educating them about the surrogate's role, completing a question prompt list, eliciting patient values, educating about treatment options, eliciting perceptions about prognosis, and providing psychosocial support resources. The interviewer also elicited stakeholders' design suggestions for such a tool. We used constant comparative methods to identify key themes that arose during the interviews.

RESULTS

Overall, 95% (55/58) of participants perceived the proposed tool to be acceptable, with 98% (57/58) of interviewees finding six or more of the seven content domains acceptable. Stakeholders identified several potential benefits of the tool including that it would help families prepare for the surrogate role and for family meetings as well as give surrogates time and a framework to think about the patient's values and treatment options. Key design suggestions included: conceptualize the tool as a supplement to rather than a substitute for surrogate-clinician communication; make the tool flexible with respect to how, where, and when surrogates can access the tool; incorporate interactive exercises; use video and narration to minimize the cognitive load of the intervention; and build an extremely simple user interface to maximize usefulness for individuals with low computer literacy.

CONCLUSION

There is broad support among stakeholders for the use of a tablet-based tool to improve communication and shared decision making in ICUs. Eliciting the perspectives of key stakeholders early in the design process yielded important insights to create a tool tailored to the needs of surrogates and care providers in ICUs.

Uninformed consent: Do medicine residents lack the proper framework for code status discussions?

BACKGROUND

Conversations eliciting patient preferences about cardiopulmonary resuscitation (CPR) are among the most common examples of informed consent. However, this is rarely recognized and therefore may not include all key elements of informed consent, namely, details and benefits of the procedure, significant risks involved, likelihood of the outcome, and alternative therapeutic options.

OBJECTIVE

Assess the content of code status discussions as reported by residents to examine whether residents meet requirements of informed consent.

DESIGN

Prospective, observational, single-center survey study.

SETTING

Internal medicine residents at an academic medical center.

INTERVENTION

Medicine residents were surveyed and data were anonymously collected.

MEASUREMENTS

Content of code status discussions and knowledge of CPR outcomes.

RESULTS

Among 100 respondents, 66% have code status discussions with most patients upon hospital admission. Two main barriers to discussing code status were lack of time (49%) and lack of rapport (29%). Only 8% reported discussing all 5 elements of informed consent. Less than 10% of the residents correctly answered questions testing knowledge regarding outcomes after cardiac arrest. In logistical regression analyses, residents who included all key elements of informed consent reported more confidence that they provided the information needed for patients to make an informed decision (odds ratio 1.7 [95% confidence interval: 1.2-2.3]).

CONCLUSIONS

Resident conversations regarding CPR are insufficient in the 5 key elements of informed consent. Framing code status discussions as examples of informed consent may be an effective strategy for educating residents or may improve the quality of these discussions, potentially leading to better patient decisions.

Clinical Impact of Education Provision on Determining Advance Care Planning Decisions among End Stage Renal Disease Patients Receiving Regular Hemodialysis in University Malaya Medical Centre

INTRODUCTION

Advance care planning (ACP) is a process of shared decision-making about future health-care plans between patients, health care providers, and family members, should patients becomes incapable of participating in medical treatment decisions. ACP discussions enhance patient's autonomy, focus on patient's values and treatment preferences, and promote patient-centered care. ACP is integrated as part of clinical practice in Singapore and the United States.

AIM

To assess the clinical impact of education provision on determining ACP decisions among end-stage renal disease patients on regular hemodialysis at University Malaya Medical Centre (UMMC). To study the knowledge and attitude of patients toward ACP and end-of-life issues.

MATERIALS AND METHODS

Fifty-six patients were recruited from UMMC. About 43 questions pretest survey adapted from Lyon's ACP survey and Moss's cardiopulmonary resuscitation (CPR) attitude survey was given to patients to answer. An educational brochure is then introduced to these patients, and a posttest survey carried out after that. The results were analyzed using SPSS version 22.0.

RESULTS

Opinion on ACP, including CPR decisions, showed an upward trend on the importance percentage after the educational brochure exposure, but this was statistically not significant. Seventy-five percent of participants had never heard of ACP before, and only 3.6% had actually prepared a written advanced directive.

CONCLUSION

The ACP educational brochure clinically impacts patients' preferences and decisions toward end-of-life care; however, this is statistically not significant. Majority of patients have poor knowledge on ACP. This study lays the foundation for execution of future larger scale clinical trials, and ultimately, the incorporation of ACP into clinical practice in Malaysia.

Knowledge and preferences regarding cardiopulmonary resuscitation: A survey among older patients

OBJECTIVE

Survival rates following cardiopulmonary resuscitation (CPR) are low for older people, and are associated with a high risk of neurological damage. This study investigated the relationship between the preferences, knowledge of survival chances, and characteristics among older people regarding CPR.

METHODS

A cross-sectional, self-administrated survey was distributed by researchers to 600 patients aged at least 50 years. The 14-question survey tool was used to collect basic demographic data, knowledge about CPR, and preference for CPR. We performed binary logistic regression analysis to predict whether patients wanted to receive CPR or not.

RESULTS

The response rate was 48%. Most respondents (84%) predicted the estimated survival rate to be higher than the actual rate. Patients were significantly less likely to want to receive CPR if they correctly estimated the survival rate, had ever contemplated CPR, were older, or female. Discussing CPR with a doctor had no influence on patient preference for CPR.

CONCLUSION

Older patients choose to receive CPR based on incorrect knowledge.

PRACTICE IMPLICATIONS

Doctors should be aware of the impact of knowing the true chances of survival on patient preference for CPR. Knowledge and skills need to be updated to provide this information to patients.

Clinical Prediction Rule for Patient Outcome after In-Hospital CPR: A New Model, Using Characteristics Present at Hospital Admission, to Identify Patients Unlikely to Benefit from CPR after In-Hospital Cardiac Arrest

BACKGROUND

Physicians and patients frequently overestimate likelihood of survival after in-hospital cardiopulmonary resuscitation. Discussions and decisions around resuscitation after in-hospital cardiopulmonary arrest often take place without adequate or accurate information.

METHODS

We conducted a retrospective chart review of 470 instances of resuscitation after in-hospital cardiopulmonary arrest. Individuals were randomly assigned to a derivation cohort and a validation cohort. Logistic Regression and Linear Discriminant Analysis were used to perform multivariate analysis of the data. The resultant best performing rule was converted to a weighted integer tool, and thresholds of survival and nonsurvival were determined with an attempt to optimize sensitivity and specificity for survival.

RESULTS

A 10-feature rule, using thresholds for survival and nonsurvival, was created; the sensitivity of the rule on the validation cohort was 42.7% and specificity was 82.4%. In the Dartmouth Score (DS), the features of age (greater than 70 years of age), history of cancer, previous cardiovascular accident, and presence of coma, hypotension, abnormal PaO2, and abnormal bicarbonate were identified as the best predictors of nonsurvival. Angina, dementia, and chronic respiratory insufficiency were selected as protective features.

CONCLUSIONS

Utilizing information easily obtainable on admission, our clinical prediction tool, the DS, provides physicians individualized information about their patients' probability of survival after in-hospital cardiopulmonary arrest. The DS may become a useful addition to medical expertise and clinical judgment in evaluating and communicating an individual's probability of survival after in-hospital cardiopulmonary arrest after it is validated by other cohorts.

The Goals of Patient Care project: implementing a proactive approach to patient-centred decision-making

BACKGROUND

Patients in the later stages of their lives risk being harmed by futile or unwanted interventions if realistic care goals and patient values are not recognised. Doctors have difficulty discussing and informing patients' healthcare goals.

AIMS

To review implementation of a Goals of Patient Care (GOPC) summary in medical inpatients and its applicability in emergency medical response (EMR) situations.

METHODS

Single-centre cross-sectional study of adult medical inpatients and adult inpatients requiring EMR at a Victorian general hospital.

MEASURES

presence and content of GOPC summary, secondary review of decision-making and discussion documentation, patient characteristics; EMR precipitants and outcomes.

RESULTS

GOPC were documented for 82 of 101 patients. One had an existing advance directive, and six had records of a patient-appointed substitute decision-maker. For patients with GOPC, 80 had life-prolonging treatment aims, with a varying degree of treatment limitation in 48. Discussion with patient or substitute decision-maker was evident in 43 cases. GOPC were documented prior to nine of 23 EMR. The EMR triggered a GOPC modification in three instances.

CONCLUSIONS

Introduction of a routine GOPC summary encourages consideration of goals of care for most medical inpatients. Few have pre-existing records of their wishes, and there are opportunities for improvement in this regard. Doctors may still have difficulty determining goals of care, and discussion of GOPC with patients and families may not be clearly documented. Most patients requiring EMR do not have prior GOPC review, and the role of the summary in these situations remains unclear.

Video decision aids to assist with advance care planning: a systematic review and meta-analysis

OBJECTIVE

Advance care planning (ACP) can result in end-of-life care that is more congruent with patients' values and preferences. There is increasing interest in video decision aids to assist with ACP. The objective of this study was to evaluate the impact of video decision aids on patients' preferences regarding life-sustaining treatments (primary outcome).

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

MEDLINE, EMBASE, PsycInfo, CINAHL, AMED and CENTRAL, between 1980 and February 2014, and correspondence with authors.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials of adult patients that compared a video decision aid to a non-video-based intervention to assist with choices about use of life-sustaining treatments and reported at least one ACP-related outcome.

DATA EXTRACTION

Reviewers worked independently and in pairs to screen potentially eligible articles, and to extract data regarding risk of bias, population, intervention, comparator and outcomes. Reviewers assessed quality of evidence (confidence in effect estimates) for each outcome using the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

10 trials enrolling 2220 patients were included. Low-quality evidence suggests that patients who use a video decision aid are less likely to indicate a preference for cardiopulmonary resuscitation (pooled risk ratio, 0.50 (95% CI 0.27 to 0.95); I(2)=65%). Moderate-quality evidence suggests that video decision aids result in greater knowledge related to ACP (standardised mean difference, 0.58 (95% CI 0.38 to 0.77); I(2)=0%). No study reported on the congruence of end-of-life treatments with patients' wishes. No study evaluated the effect of video decision aids when integrated into clinical care.

CONCLUSIONS

Video decision aids may improve some ACP-related outcomes. Before recommending their use in clinical practice, more evidence is needed to confirm these findings and to evaluate the impact of video decision aids when integrated into patient care.

Trends in in-hospital cardiopulmonary resuscitation and survival in adults receiving maintenance dialysis

IMPORTANCE

Understanding cardiopulmonary resuscitation (CPR) practices and outcomes can help to support advance care planning in patients receiving maintenance dialysis.

OBJECTIVE

To characterize patterns and outcomes of in-hospital CPR in US adults receiving maintenance dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This national retrospective cohort study studied 663,734 Medicare beneficiaries 18 years or older from a comprehensive national registry for end-stage renal disease who initiated maintenance dialysis from January 1, 2000, through December 31, 2010.

EXPOSURES

Receipt of in-hospital CPR from 91 days after dialysis initiation through the time of death, first kidney transplantation, or end of follow-up on December 31, 2011.

MAIN OUTCOMES AND MEASURES

Incidence of CPR and survival after the first episode of CPR recorded in Medicare claims during follow-up.

RESULTS

The annual incidence of CPR for the overall cohort was 1.4 events per 1000 in-hospital days (95% CI, 1.3-1.4). A total of 21.9% CPR recipients (95% CI, 21.4%-22.3%) survived to hospital discharge, with a median postdischarge survival of 5.0 months (interquartile range, 0.7-16.8 months). Among patients who died in the hospital, 14.9% (95% CI, 14.8%-15.1%) received CPR during their terminal admission. From 2000 to 2011, there was an increase in the incidence of CPR (1.0 events per 1000 in-hospital days; 95% CI, 0.9-1.1; to 1.6 events per 1000 in-hospital days; 95% CI, 1.6-1.7; P for trend <.001), the proportion of CPR recipients who survived to discharge (15.2%; 95% CI, 11.1%-20.5%; to 28%; 95% CI, 26.7%-29.4%; P for trend <.001), and the proportion of in-hospital deaths preceded by CPR (9.5%; 95% CI, 8.4%-10.8%; to 19.8%; 95% CI, 19.2%-20.4%; P for trend <.001), with no substantial change in duration of postdischarge survival.

CONCLUSIONS AND RELEVANCE

Among a national cohort of patients receiving maintenance dialysis, the incidence of CPR was higher and long-term survival worse than reported for other populations.

A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial

OBJECTIVE

To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU.

DESIGN

Randomized, unblinded trial.

SETTING

Single medical ICU.

PATIENTS

Patients and surrogate decision makers in the ICU.

INTERVENTIONS

The usual care group received a standard pamphlet about cardiopulmonary resuscitation and cardiopulmonary resuscitation preference options plus routine code status discussions with clinicians. The video group received usual care plus an 8-minute video that depicted cardiopulmonary resuscitation, showed a simulated hospital code, and explained resuscitation preference options.

MEASUREMENTS AND MAIN RESULTS

One hundred three patients and surrogates were randomized to usual care. One hundred five patients and surrogates were randomized to video plus usual care. Median total knowledge scores (0-15 points possible for correct answers) in the video group were 13 compared with 10 in the usual care group, p value of less than 0.0001. Video group participants had higher rates of understanding the purpose of cardiopulmonary resuscitation and resuscitation options and terminology and could correctly name components of cardiopulmonary resuscitation. No statistically significant differences in documented resuscitation preferences following the interventions were found between the two groups, although the trial was underpowered to detect such differences. A majority of participants felt that the video was helpful in cardiopulmonary resuscitation decision making (98%) and would recommend the video to others (99%).

CONCLUSIONS

A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU, compared with receiving a pamphlet on cardiopulmonary resuscitation. Patients and surrogates found the video helpful in decision making and would recommend the video to others.

Quality of communication in the ICU and surrogate's understanding of prognosis

OBJECTIVE

Although misperceptions about prognosis by surrogates in ICUs are common and influence treatment decisions, there is no validated, practical way to measure the effectiveness of prognostic communication. Surrogates' subjective ratings of quality of communication have been used in other domains as markers of effectiveness of communication. We sought to determine whether surrogates' subjective ratings of the quality of prognostic communication predict accurate expectation about prognosis by surrogates.

DESIGN

We performed a cross-sectional cohort study. Surrogates rated the quality of prognostic communication by survey. Physicians and surrogates gave their percentage estimate of patient survival on ICU day 3 on a 0-100 probability scale. We defined discordance about prognosis as a difference in the physician's and surrogate's estimates of greater than or equal to ±20%. We used multilevel logistic regression modeling to account for clustering under physicians and patients and adjust for confounders.

SETTING

Medical-surgical, trauma, cardiac, and neurologic ICUs of five U.S. academic medical centers located in California, Pennsylvania, Washington, North Carolina, and Massachusetts.

PATIENTS

Two hundred seventy-five patients with acute respiratory distress syndrome at high risk of death or severe functional impairment, their 546 surrogate decision makers, and their 150 physicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There was no predictive utility of surrogates' ratings of the quality of communication about prognosis to identify inaccurate expectations about prognosis (odds ratio, 1.04 ± 0.07; p = 0.54). Surrogates' subjective ratings of the quality of communication about prognosis were high, as assessed with a variety of questions. Discordant prognostic estimates were present in 63.5% (95% CI, 59.0-67.9) of physician-surrogate pairs.

CONCLUSIONS

Although most surrogates rate the quality of prognostic communication high, inaccurate expectations about prognosis are common among surrogates. Surrogates' ratings of the quality of prognostic communication do not reliably predict an accurate expectation about prognosis.

Long-term outcomes after in-hospital CPR in older adults with chronic illness

BACKGROUND

Outcomes after in-hospital CPR in older adults with chronic illness are unclear.

METHODS

We examined inpatient Medicare data from 1994 through 2005 to identify CPR recipients. We grouped beneficiaries aged ≥ 67 years by severity of six chronic diseases-COPD, congestive heart failure (CHF), chronic kidney disease (CKD), malignancy, diabetes, and cirrhosis-and investigated survival to discharge, discharge destination, rehospitalizations, and long-term survival.

RESULTS

We identified 358,682 CPR recipients. Most patients with chronic disease were less likely to survive to discharge (eg, 14.8% in the advanced COPD group [P < .001] and 11.3% in the advanced malignancy group [P < .001]) than patients without chronic illness (17.3%). Among discharge survivors, the median long-term survival was shorter in patients with chronic illness (eg, 5.0, 3.5, and 2.8 months in the advanced COPD, malignancy, and cirrhosis groups, respectively; P < .001 for all) than without (26.7 months). Although 7.2% of CPR recipients without chronic disease were discharged home and survived at least 6 months without readmission, ≤ 2.0% of recipients with advanced COPD, CHF, malignancy, and cirrhosis (P < .001 for all) met these criteria. Adjusted analyses confirmed that most subgroups with chronic illness had lower hospital discharge survival, and among discharge survivors, most were discharged home less often, experienced more hospital readmissions, and had worse long-term survival.

CONCLUSIONS

Older CPR recipients with any of the six underlying chronic diseases investigated generally have much worse outcomes than CPR recipients without chronic disease. These findings may substantially affect decisions about CPR in patients with chronic illness.

What CPR means to surrogate decision makers of ICU patients

AIM OF THE STUDY

The decision to accept or decline cardiopulmonary resuscitation (CPR) by surrogate decision makers on behalf of a family member is a common and important component of end-of-life decision-making in the ICU. While many determinants influence this decision, surrogates' understanding of CPR may be a major guiding factor. However, little is known about surrogates' knowledge and perceptions of CPR during the periods of time when their family member is critically ill. We conducted this study to explore surrogates' understanding of some basic concepts of CPR.

METHODS

This is a descriptive, survey-based exploratory study of understanding of CPR concepts and outcomes conducted in a single-center medical ICU at a tertiary academic hospital in the United States. Study subjects were surrogate decision-makers of critically ill ICU patients who participated in an interview-format survey within 24h of the patient's ICU admission.

RESULTS

Of 97 eligible subjects (surrogates), 50 were enrolled in this study and represented a wide spectrum of demographics. All subjects had heard of CPR. The main source of information about CPR was a course. While 46% identified cardiac arrest as a main indication for CPR, only 8% identified at least 2 of the 3 main components of CPR. The majority (72%) believed survival after CPR was ≥75%. Forty-two percent of surrogates had spoken to the patient about CPR prior to coming to the hospital, and 57% had spoken to the physician during this hospitalization. Twenty-six percent changed their decision on CPR during the ICU stay.

CONCLUSION

There is a wide variation in surrogates' understanding and knowledge of CPR concepts and outcomes.