Randomized Controlled Trial of a Video Decision Support Tool for Cardiopulmonary Resuscitation Decision Making in Advanced Cancer

Abstract

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.

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

“…Previous work included multi-center, randomized trials of patients with advanced illnesses who were making decisions about treatment options and goals of care in the outpatient setting. [17][18][19] Patients who viewed the video tools were more knowledgeable about their choices and were less likely to opt for aggressive medical interventions. However, our previous work was limited by several factors, including: use of hypothetical scenarios in which patients were asked to imagine a specific disease state, 19 lack of evaluation of the impact the video tools have on the actual care of the patient, [17][18][19] and limitation to the ambulatory setting.…”

“…[17][18][19] Patients who viewed the video tools were more knowledgeable about their choices and were less likely to opt for aggressive medical interventions. However, our previous work was limited by several factors, including: use of hypothetical scenarios in which patients were asked to imagine a specific disease state, 19 lack of evaluation of the impact the video tools have on the actual care of the patient, [17][18][19] and limitation to the ambulatory setting. [17][18][19] Extending this research to the hospital setting is important, as advance directives are often implemented when patients are acutely ill.…”

“…The research team (A.E.V, M.K.P.-O, and A.D.D) performed all filming and editing of the video following previously published filming criteria prior to this study's protocol development. 17,18,20,21 All patients included in the video (or their proxies) gave consent to be filmed.…”

“…However, our previous work was limited by several factors, including: use of hypothetical scenarios in which patients were asked to imagine a specific disease state, 19 lack of evaluation of the impact the video tools have on the actual care of the patient, [17][18][19] and limitation to the ambulatory setting. [17][18][19] Extending this research to the hospital setting is important, as advance directives are often implemented when patients are acutely ill. Importantly, extending this research beyond hypothetical scenarios to include the use of video tools in a real-time health care setting for seriously ill hospitalized patients will allow us to examine its impact on the actual medical care delivered to patients, and documented CPR and intubation preferences in the medical record, as well as any real-time discussions with physicians regarding the topic.…”

Institute of Medicine Recommendations for Improving the Quality of Cancer Care: What Do They Mean for the General Internist?

“…The IOM emphasized that patients with advanced cancer must be provided with palliative care, psychosocial support, and timely referral to hospice care for end-of-life care. Prior studies show that patients often have inaccurate perceptions about prognosis, leading to receipt of burdensome treatments at the end of life, 10,11 that patients may alter end-of-life treatment requests when adequately informed, 12 and that outcomes may be improved when patients engage in palliative care. 13 General internists are well positioned to offer a clinical perspective on the overall health status of those with advanced cancer and to discuss end-of-life care.…”