Purpose Decision making regarding cardiopulmonary resuscitation (CPR) is challenging. This study examined the effect of a video decision support tool on CPR preferences among patients with advanced cancer. Patients and Methods We performed a randomized controlled trial of 150 patients with advanced cancer from four oncology centers. Participants in the control arm (n = 80) listened to a verbal narrative describing CPR and the likelihood of successful resuscitation. Participants in the intervention arm (n = 70) listened to the identical narrative and viewed a 3-minute video depicting a patient on a ventilator and CPR being performed on a simulated patient. The primary outcome was participants' preference for or against CPR measured immediately after exposure to either modality. Secondary outcomes were participants' knowledge of CPR (score range of 0 to 4, with higher score indicating more knowledge) and comfort with video. Results The mean age of participants was 62 years (standard deviation, 11 years); 49% were women, 44% were African American or Latino, and 47% had lung or colon cancer. After the verbal narrative, in the control arm, 38 participants (48%) wanted CPR, 41 (51%) wanted no CPR, and one (1%) was uncertain. In contrast, in the intervention arm, 14 participants (20%) wanted CPR, 55 (79%) wanted no CPR, and 1 (1%) was uncertain (unadjusted odds ratio, 3.5; 95% CI, 1.7 to 7.2; P < .001). Mean knowledge scores were higher in the intervention arm than in the control arm (3.3 ± 1.0 v 2.6 ± 1.3, respectively; P < .001), and 65 participants (93%) in the intervention arm were comfortable watching the video. Conclusion Participants with advanced cancer who viewed a video of CPR were less likely to opt for CPR than those who listened to a verbal narrative.

Background Conversations about goals of care and CPR/intubation for patients with advanced health failure (HF) can be difficult. This study examined the impact of a video decision support tool and a patient checklist on advance care planning (ACP) for patients with HF. Methods Multi-site randomized controlled trial of a video-assisted intervention and ACP checklist versus a verbal description in 246 patients ≥ 64 years with HF and an estimated likelihood of death of > 50% within two years. Intervention participants received a verbal description for goals of care (life-prolonging care, limited care, and comfort care) and CPR/intubation plus a six-minute video depicting the three levels of care and CPR/intubation as well as ACP checklist. Controls received only the verbal description. The primary analysis compared the proportion of patients preferring comfort care between study arms immediately after the intervention. Secondary outcomes were CPR/intubation preferences and knowledge (6-item test, range 0-6) after intervention. Results In the intervention group, 27 (22%) chose life-prolonging, 31 (25%) limited, 63 (51%) comfort, with two (2%) uncertain. In the control group, 50 (41%) chose life-prolonging, 27 (22%) limited, 37 (30%) comfort, with eight (7%) uncertain (P<0.001). Intervention participants (vs. controls) were more likely to forgo CPR (68% vs. 35%, P <0.001) and intubation (77% vs. 48%, P <0.001), and had higher mean knowledge scores (4.1 vs. 3.0; P < 0.001). Conclusions Patients with HF who viewed a video were more informed, more likely to select a focus on comfort, and less likely to desire CPR/intubation compared to patients receiving verbal information only.

Objective: To determine the impact of a video on preferences for the primary goal of care. Design, subjects, and intervention: Consecutive subjects 65 years of age or older (n = 101) admitted to two skilled nursing facilities (SNFs) were randomized to a verbal narrative (control) or a video (intervention) describing goals-of-care options. Options included: life-prolonging (i.e., cardiopulmonary resuscitation), limited (i.e., hospitalization but no cardiopulmonary resuscitation), or comfort care (i.e., symptom relief). Main measures: Primary outcome was patients' preferences for comfort versus other options. Concordance of preferences with documentation in the medical record was also examined. Results: Fifty-one subjects were randomized to the verbal arm and 50 to the video arm. In the verbal arm, preferences were: comfort, n = 29 (57%); limited, n = 4 (8%); life-prolonging, n = 17 (33%); and uncertain, n = 1 (2%). In the video arm, preferences were: comfort, n = 40 (80%); limited, n = 4 (8%); and life-prolonging, n = 6 (12%). Randomization to the video was associated with greater likelihood of opting for comfort (unadjusted rate ratio, 1.4; 95% confidence interval [CI], 1.1-1.9, p = 0.02). Among subjects in the verbal arm who chose comfort, 29% had a do-not-resuscitate (DNR) order (j statistic 0.18; 95% CI-0.02 to 0.37); 33% of subjects in the video arm choosing comfort had a DNR order (j statistic 0.06; 95% CI-0.09 to 0.22). Conclusion: Subjects admitted to SNFs who viewed a video were more likely than those exposed to a verbal narrative to opt for comfort. Concordance between a preference for comfort and a DNR order was low. These findings suggest a need to improve ascertainment of patients' preferences. Trial Registration: Clinicaltrials.gov Identifier: NCT01233973.

This study illustrates the difficulties that GPs may have in applying the relevant evidence for the successful management of back pain. A desire to avoid conflict in the relationship with patients explained much of the problem of implementing evidence in general practice. This indicates a need for insightful educational strategies that involve active GP participation.

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Barriers to implementation of the RCGP Guideline and to a nurse-led acute back pain service in general practice, were illustrated. These mainly relate to grossly inadequate capacity to deal with multidimensional patient needs, allowing progression to chronic pain states and much higher health care costs. There was a strong desire to include a different group of professionals in primary care. We recommend a local needs assessment and consideration of a national strategy for the implementation of the RCGP Guideline in primary care.

There is compelling evidence that despite growing research into the complex neurophysiology of pain, the development of acute pain services, increasing educational interest in pain management and the proliferation of literature, many patients continue to suffer from unrelieved acute pain while in hospital. Educational efforts to bring about a change in practice have been relatively unsuccessful or slow to have real impact. Although it is still recognized that poor knowledge of pain control by all healthcare professionals is the major barrier to improving pain management, contemporary studies show that other, more subtle barriers can just as effectively inhibit a timely and effective response to patients' reports of pain. These barriers are not just the ones created by poor knowledge, myth and misconception; the most powerful barriers to change may be the invisible institutional barriers that can be entrenched within hospital policies and nursing rituals.

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