‘It's not magic’: A qualitative analysis of geriatric physicians' explanations of cardio‐pulmonary resuscitation in hospital admissions

Abstract

Background Discussing patient preferences for cardio‐pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making. Objective The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations. Method We recorded forty‐three physician‐patient admission interviews taking place in a hospital in French‐speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English. Results Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers. Discussion and conclusions The scarcity and simplicity of CPR explanations highlight a reluctance to have in‐depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient‐centred care. Patient contribution Patients were involved in the data collection stage of the study.

Developing Guidelines On Code Status Conversations With Older Adults Upon Hospital Admission: Results From A Survey Of Experienced Healthcare Professionals

“…Still, by informing patients about the reasons of non-indication, respecting their values and addressing their concerns, physicians ful ll their role of supporting patients in recalibrating their expectations and wishes towards medically-relevant options. Moreover, viewed through an ethical lens of non-male cence and justice, excluding some patients from the CPR discussion may be harmful if it lets patients believe that they would bene t from a procedure that is not indicated [12]. Patients who would not bene t from CPR still have a right to be informed of the medical procedures that could be envisaged or not, and why this is in their best interest.…”

“…Secondly, patients' chances of survival, life goals and preferences are not systematically discussed [7][8][9][10]. Thirdly, some physicians may "nudge" patients towards a preferred option by way of depicting certain procedures in an overly negative or positive manner [8,11,12] or by way of formulating their questions [13]. Finally, in some instances, CPR is not discussed with patients who might not be considered ill enough or for whom the discussion might be deemed overly upsetting [14].…”

“If I Become a Vegetable, Then no”: A Thematic Analysis of How Patients and Physicians Refer to Prognosis When Discussing Cardiopulmonary Resuscitation

“…Expression of this uncertainty by physicians, however, is equated with ignorance and failure by patients (Simpkin & Armstrong, 2019). Furthermore, documentation of CPR decisions is required at hospital admission when physicians are unfamiliar with patients, rendering the judgment on the medical indication of CPR rather abstract (A. C. Sterie et al, 2021). Lastly, physicians feel ill-equipped to communicate prognostic information and require more adapted training (Bloom et al, 2022).…”

Decision-making ethics in regards to life-sustaining interventions: when physicians refer to what other patients decide

“…In this sense, one thing worth noting is that the context in which these discussions are led is perhaps not the most conducive for their finality. As we argue in our previous works [5,6], admission interviews are primarily concerned with obtaining information from the patient (medical history, physical and cognitive exams). It is of no surprise that code status is addressed as an information that patients have and give to the physician, when in reality, this is by no means a unidirectional moment but a decisional one, in which choices should be made or reassessed, with the participation of both the physician and the patient.…”

“…Research shows that CPR discussions are a frequent cause of ethical difficulty [ 2 – 4 ]. Our own results [ 5 ] show that explanations provided by hospital physicians about the CPR procedure are scarce, and, when existent, sketchy and simplistic, overlooking aspects related to prognosis or risk of adverse outcomes. Physicians seem to take for granted that CPR is understood by everyone and does not warrant explanation.…”