Cardiopulmonary resuscitation policies in long-term care facilities

Default options in the ICU: widely used but insufficiently understood

PURPOSE OF REVIEW

Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology.

RECENT FINDINGS

Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking.

SUMMARY

Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.

Helping patients make better decisions: how to apply behavioral economics in clinical practice

Clinicians are committed to effectively educating patients and helping them to make sound decisions concerning their own health care. However, how do clinicians determine what is effective education? How do they present information clearly and in a manner that patients understand and can use to make informed decisions? Behavioral economics (BE) is a subfield of economics that can assist clinicians to better understand how individuals actually make decisions. BE research can help guide interactions with patients so that information is presented and discussed in a more deliberate and impactful way. We can be more effective providers of care when we understand the factors that influence how our patients make decisions, factors of which we may have been largely unaware. BE research that focuses on health care and medical decision making is becoming more widely known, and what has been reported suggests that BE interventions can be effective in the medical realm. The purpose of this article is to provide clinicians with an overview of BE decision science and derived practice strategies to promote more effective behavior change in patients.

Resuscitation decisions in Irish long-stay units

BACKGROUND

Little is known of how cardiopulmonary resuscitation (CPR) decisions are made in Irish long-term care settings.

AIM

To examine how CPR decisions are made in Irish long-stay units and those factors associated with use or non-use of CPR.

METHODS

We surveyed each public long-stay unit and a random sample of private nursing homes across the country.

RESULTS

Of the 84 long-stay units that responded (response rate 58%), basic CPR had been performed in 32% and advanced CPR (including defibrillation) in 10%. Only 13% of the units had a written CPR policy. Units performing CPR (N = 35) were closer to an acute hospital, more likely to have short-term residents and more likely to have a CPR policy (all P < 0.05). There were no significant differences between public and private units.

CONCLUSION

The widely disparate approaches to CPR in different Irish long-stay units suggest the need for national guidelines on this issue.

Cardiopulmonary resuscitation in older people – a review

Survival to discharge after in-hospital cardiopulmonary resuscitation (CPR) is about 20% in those aged 65–69 years, declining with advancing age to about 10% in those aged 90 years or more. There are conflicting reports on whether or not advanced age, independent of the severity of acute and chronic illness, is a determinant of outcome. Recognition that the outcome of CPR in hospital patients is often poor has prompted extensive debate regarding the appropriate use of this procedure. In particular, there has been concern about unnecessary CPR in extended-care and hospice settings. Conversely, there has also been evidence that doctors and families may be prone to underestimate the quality of life and likelihood of benefit from CPR in older people and to make resuscitation decisions without considering the preferences of older people themselves. Recent guidelines have attempted to strike a balance between ensuring patient participation whenever possible but without offering illusory choices where CPR is very unlikely to succeed.

Developing Quality Indicators for the Appropriateness of Resuscitation in Prehospital Atraumatic Cardiac Arrest

OBJECTIVE

The vast majority of out-of-hospital cardiac arrest victims do not survive or suffer severe neurological impairment. We sought to develop a set of straightforward clinical indicators that paramedics could use to better match resuscitation attempts to those most likely to benefit.

METHODS

In partnership with the Los Angeles County Emergency Medical Services, we used the RAND/UCLA appropriateness method of quantifying expert opinion regarding the risks and benefits of medical procedures. We presented available scientific evidence related to potential indicators of the quality of resuscitative care to stakeholder-nominated experts. Forty-one candidate indicators incorporated key variables, including initial rhythm, patient preferences, presence of witnesses, and place of arrest. Nine panelists, including palliative care and emergency medical specialists, rated the appropriateness of paramedic use of each indicator by using a 1-9 scale. An indicator was considered appropriate if the potential benefits outweighed the potential harm to the patient or their family. Indicators were retained if median score was >/=7.

RESULTS

The expert panel voted to retain 28 quality indicators. Three addressed signs of irreversible death (e.g., dependent lividity), 8 addressed patient preferences (e.g., inquiring about DNR status), and the remainder addressed combinations of initial rhythm and other prognostic signs (e.g., "If initial rhythm is asystole and patient is known by apparent surrogate decision maker to have a terminal illness, then forgo resuscitation."). Our experts recommended a series of much more liberal criteria for forgoing resuscitation than is currently practiced. This includes ascertaining and honoring patient preferences, either through written documents or family members, and combinations of clinical criteria that predict poor neurological outcome, such as asystole, terminal illness, age greater than 70, and response time greater than 15 minutes.

CONCLUSIONS

These quality indicators expand on the previously limited circumstances in which paramedics might forgo field resuscitation and implementation could reduce future harm from such procedures among seriously ill patients. Our current efforts focus on using these indicators to aid implementation of a new resuscitation policy for seriously ill patients in our county.

Cardiac Arrests in Skilled Nursing Facilities: Continuing Room for Improvement?

OBJECTIVES

To characterize the care received by skilled nursing facility (SNF/NF) patients suffering cardiac arrest and to evaluate the outcome of SNF/NF patients experiencing cardiac arrest.

DESIGN

A retrospective analysis of an existing cardiac arrest registry to characterize SNF/NF cardiac arrest patients and to compare them to community-dwelling cardiac arrest patients was performed.

SETTING

The study took place in Rochester, NY, an urban city in upstate New York with approximately 220,000 residents.

PARTICIPANTS

All patients for whom emergency medical services (EMS) assistance was requested via the 911 system and who were treated for cardiac arrest between January 1998 and December 2001 were included.

MEASUREMENTS

Demographic characteristics such as age, gender, race; clinical characteristics and interventions such as cardiopulmonary resuscitation (CPR), defibrillation, initial cardiac rhythm, and call response interval; outcomes measures such as return of spontaneous circulation and 1-year survival were obtained.

RESULTS

Forty-two (8%) of cardiac arrest patients resided in an SNF/NF. Sixteen (38%) of the events were witnessed arrests. Only 28 (67%) patients received CPR and none were defibrillated prior to EMS arrival. One (2%) patient was alive 1 year after the event, a survival rate similar to the community-dwelling population (5%).

CONCLUSION

SNF/NF patients suffering cardiac arrest often did not receive CPR or defibrillation while awaiting EMS arrival. SNF/NF patients suffering cardiac arrest have a very low survival rate, similar to the community-dwelling population. The impact of not providing CPR and defibrillation on the survival rate is unclear, but needs to be evaluated prior to any decisions regarding the medical futility of resuscitating SNF/NF patients.

Cardiac Arrests in Skilled Nursing Facilities: Continuing Room for Improvement?

OBJECTIVES

To characterize the care received by skilled nursing facility (SNF/NF) patients suffering cardiac arrest and to evaluate the outcome of SNF/NF patients experiencing cardiac arrest.

DESIGN

A retrospective analysis of an existing cardiac arrest registry to characterize SNF/NF cardiac arrest patients and to compare them to community-dwelling cardiac arrest patients was performed.

SETTING

The study took place in Rochester, NY, an urban city in upstate New York with approximately 220,000 residents.

PARTICIPANTS

All patients for whom emergency medical services (EMS) assistance was requested via the 911 system and who were treated for cardiac arrest between January 1998 and December 2001 were included.

MEASUREMENTS

Demographic characteristics such as age, gender, race; clinical characteristics and interventions such as cardiopulmonary resuscitation (CPR), defibrillation, initial cardiac rhythm, and call response interval; outcomes measures such as return of spontaneous circulation and 1-year survival were obtained.

RESULTS

Forty-two (8%) of cardiac arrest patients resided in an SNF/NF. Sixteen (38%) of the events were witnessed arrests. Only 28 (67%) patients received CPR and none were defibrillated prior to EMS arrival. One (2%) patient was alive 1 year after the event, a survival rate similar to the community-dwelling population (5%).

CONCLUSION

SNF/NF patients suffering cardiac arrest often did not receive CPR or defibrillation while awaiting EMS arrival. SNF/NF patients suffering cardiac arrest have a very low survival rate, similar to the community-dwelling population. The impact of not providing CPR and defibrillation on the survival rate is unclear, but needs to be evaluated prior to any decisions regarding the medical futility of resuscitating SNF/NF patients.

Transferring dying nursing home residents to the hospital: DON perspectives on the nurse's role in transfer decisions

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution's mission and the nursing service's values.

Advance directives: older adults with dementia

The benefits and risks for older adults with dementia executing advance directives are discussed. Salient issues related to decision-specific capacity and models for advance planning and end-of-life decisions by cognitively impaired older adults are presented.