A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients

Abstract

BACKGROUND: Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. OBJECTIVES: We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. DESIGN: This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. PARTICIPANTS: One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51 % were women. INTERVENTION: Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N=75) or control arm (usual care) (N=75). MAIN MEASURES: The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). RESULTS: Intervention participants (vs. controls) were more likely not to want CPR (64 % vs. 32 %, p <0.0001) and intubation (72 % vs. 43 %, p<0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57 % vs. 19 %, p<0.0001) and intubation (64 % vs.19 %, p<0.0001) by hospital discharge, documented discussions about their preferences (81 % vs. 43 %, p<0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p<0.0001).CONCLUSIONS: Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers. Trial registration: Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.

Improving End-of-Life Decision-Making About Resuscitation and Intubation

“…8 More research on how to increase communication about end-of-life issues and improve the quality of that communication using methods that can be implemented in actual practice is greatly needed. The study by El-Jawahri and colleagues 4 is an important step in that direction and adds to a growing body of research that more and improved communication about these issues is possible, can be practically implemented and can improve outcomes. Future developments in decision support tools, such as interactive methods that can be incorporated into the electronic medical record in the course of clinical practice, 9 as well as through electronic patient portals and "living" documents that can evolve over time and go beyond preferences for resuscitation and intubation to address other elements of communication about serious illness, may help to advance care in these areas.…”

“…The study by El-Jawahri and colleagues 4 has some limitations. The participants were mostly white; other patient groups should be studied since they may have different needs and preferences.…”

“…5 In this study with a larger sample size (208 patients), the control group received a 16-page pamphlet and all participants participated in a code status discussion (compared to El-Jawahri and colleagues 4 where the control group received no intervention at all). Median total knowledge scores were statistically significantly higher in the intervention group (13 compared to 10 on a 15-point scale), but there were no significant differences in documented preferences between the two groups (5 % in the intervention group compared to 6 % in the control group changed preferences to do-not-resuscitate within 72 h).…”

“…In this issue of the Journal of General Internal Medicine, ElJawahri and colleagues 4 report the results of a randomized trial of a simple and practical video education intervention to inform patients about resuscitation and intubation. This research team, part of the Video Images of Disease for Ethical Outcomes (VIDEO) consortium, used rigorous methods to develop and evaluate this decision support tool.…”

Caring for the Complex Patient: The Next Hurdle for Information Technology Is Care Coordination

“…One factor driving such complexity is the need to understand, incorporate, and integrate the values of patients, family members, and clinicians. In a randomized trial reported in this issue, El-Jawahri et al 4 evaluated an educational video that teaches medical inpatients about intubation and cardiopulmonary resuscitation (CPR). Based on a framework developed by co-author Angelo Volandes and popularized in his book (The Conversation, Bloomsbury, 2015), the videos were designed to help patients understand what to expect from these procedures.…”