Chest

Chest

Volume 130, Issue 2, August 2006, Pages 419-428
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Original Research: CRITICAL CARE MEDICINE
Understanding Cardiopulmonary Resuscitation Decision Making: Perspectives of Seriously Ill Hospitalized Patients and Family Members

https://doi.org/10.1378/chest.130.2.419Get rights and content

Background

To improve communication and decision making related to cardiopulmonary resuscitation (CPR), a greater understanding of the perspectives of hospitalized patients with advanced diseases and their family members are needed.

Methods

In five Canadian hospitals, we administered a face-to-face questionnaire to older inpatients with end-stage cancer and advanced medical diseases and, where possible, to one of their family members, regarding information needs, the deliberation process, and their preferred decisional role.

Findings

A total of 440 of 569 patients (78%) and 160 of 176 available caregivers (91%) agreed to participate. Most patients (61%) had thought about what treatment they wanted if their heart stopped, few patients (11.3%) could describe more than two components of CPR, and only 2.7% of patients thought that the success rate of CPR was < 10%. A minority of patients (34%) had discussed CPR with their physician; 37% did not want to discuss their preferences with their doctor. Patients who felt that end-of-life issues were relevant to them were 5.5 times more likely to want a discussion with the physician regarding resuscitation (odds ratio, 5.5; 95% confidence interval, 2.5 to 12.0). The preferred role in decision making was variable, but most patients (59.7%) and family members (81.6%) preferred some degree of shared decision making that included the family member. There were no significant differences between cancer and medical patients in their preferred decisional role.

Interpretation

Seriously ill hospitalized patients have poor knowledge about CPR, and variable preferences for deliberation and their role in the decision-making process regarding their treatment. Strategies that improve understanding of CPR and foster discussions that involve patients, family members, and physicians in the decision-making process may improve the quantity and quality of communication and decision making about CPR.

Section snippets

MATERIALS AND METHODS

This study was a cross-sectional survey conducted at five tertiary acute care teaching hospitals across Canada, ranging from 400 to 520 acute care beds. Each site admitted seriously ill patients under the care of a primary service (eg, general medicine or respirology). Palliative care, social work, clinical ethics, and other consultation services with health-care professionals were available on request. The research ethics boards at each participating institution approved the study.

Study Population

Patients were eligible if they met the following inclusion criteria: age > 55 years; and one or more of the following comorbidities at an advanced stage:

  • 1.

    COPD: at least two of the four following conditions: baseline Paco2 of ≥ 45 mm Hg; cor pulmonale; respiratory failure episode within the preceding year; and FEV1 of ≤ 0.75 L.

  • 2.

    Congestive heart failure: New York Heart Association class IV symptoms or left ventricular ejection fraction of ≤ 25%.

  • 3.

    Cirrhosis: confirmed by imaging studies or

Questionnaire Development

The details of survey development and pretesting have been reported elsewhere.16 In brief, the development of the entire questionnaire was based on conceptual frameworks that were related to quality EOL care or interviews with patients and families.16 The overall questionnaire consisted of two parts. The first part, which focused on issues related to quality care at the EOL and the respondent's views on its importance and their satisfaction with the care, has been reported elsewhere.16 The

Data Collection

At each hospital, a research nurse screened patient charts to identify potential participants from Monday to Friday. The research nurse approached suitable patients, and informed consent was obtained. The family members of enrolled patients were also approached for consent. Both patients and family members were then administered the questionnaire in independent, face-to-face interviews, usually on the same day. To facilitate answering the questions with categoric responses, we provided cards

Statistical Analysis

As the main purpose of this study was descriptive, we set out to obtain a consecutive sample of 100 eligible patients in each of the five participating hospitals. A sample size of 100 reflected a population that was considered to be large enough to provide a representative sample of responses for each local participating hospital. The baseline demographics of participating patients and family members are described using means, SDs, frequency counts, and percentages. Differences between cancer

RESULTS

A total of 569 eligible patients were identified and approached for consent at the five participating hospitals, and 447 patients consented for an overall response rate of 78.6%. Six patients withdrew from the study after beginning the interviews, and one patient died on the day before the interview. Of the participants, 226 patients (50.5%) had a family member who could potentially participate. However, due to logistical reasons, not all family members could be approached; of the 176 available

Information Exchange

Table 2summarizes patients' knowledge about CPR, and their preferences and preferred roles in CPR discussions. Patients without cancer reported a higher frequency of CPR in the past (18.2% vs 8.4% of cancer patients, respectively; p < 0.05). The majority of patients could not describe the treatments performed on people during CPR, and more cancer patients than medical patients could not identify any of the key elements of CPR (53.6% vs 38.7%, respectively; p < 0.05). Less than 3% of all

Deliberation

When asked about who should be involved in the deliberation, 23.2% of patients wished to do this on their own. A small number of patients (8.2%) wished the hospital physician alone to be the main person making the decision, and 34.1% wished a combination of patient/family/MD to deliberate (Table 2). In the situation in which the patient was too sick to participate, 51.9% of family members saw the deliberation process as involving themselves, other family members, and the doctor; 24.4% preferred

Decision Making

In their current health state; 22.5% of patients wished to make the decision themselves, 26.6% desired joint decision making with patient and physician, and 26.8% wished to make the decision with physician input (Table 2). There was no difference between cancer and noncancer patients in terms of the preference for decisional responsibility. Female patients were more likely to prefer a shared or physician-only decision-making model (OR, 1.8; 95% CI, 1.05 to 3.02; p = 0.033).

If the patient was

DISCUSSION

Studies of satisfaction with EOL care suggest that improvements in communication and decision making among patients, families, and providers are likely to have the greatest impact on improving the quality of EOL care.2021 Before we can improve the situation with regard to decisions about resuscitation, we need to have a better understanding of patient and family perspectives. This is the first study that comprehensively describes the views of older hospitalized patients with life-limiting

CONCLUSIONS

Patients who have advanced cancer and medical illnesses and are admitted to acute care hospitals do not have good knowledge about CPR. However, more than a third of patients did not wish to discuss preferences with their physician, and those patients who had a poorer understanding of their prognosis were less willing to have these discussions. Most patients prefer shared decision making with family and physician involvement. There are no significant differences between cancer and advanced

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    Copyright © 2006 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.