The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation

Murphy, Douglas B.; Burrows, David; Santilli, Sara; Kemp, Anne W.; Tenner, Scott; Kreling, Barbara; Teno, Joan M.

doi:10.1056/nejm199402243300807

Cited by 530 publications

(288 citation statements)

References 43 publications

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“…Efforts to resolve disagreements should therefore include exploration of differences in perception. Only a tiny minority of patients would request resuscitation if they understood their prognosis to be very poor 16 , and others have suggested effective ways to discuss prognosis 19 . Table 3.…”

Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

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BACKGROUND:The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS:We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS:We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

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Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

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“…24 There is conflicting evidence regarding patients' treatment preferences at the end of life. Fried et al reported that the burden of treatment, its outcomes and the likelihood of its outcomes all influenced the treatment preferences of older patients who were seriously ill. 25 Unrealistically optimistic expectations of the outcomes of treatment can also lead patients to request interventions, such as cardiopulmonary resuscitation (CPR), that doctors believe are inappropriate. Patients' choices are influenced by the provision of accurate information regarding the outcomes of treatment; one study demonstrated that patients were far less likely to request CPR when they were made aware of the low probability of a successful outcome.…”

Section: Planning Of End-of-life Carementioning

confidence: 99%

‘If only someone had told me…': A review of the care of patients dying in hospital

Edmonds

Rogers

2003

Clinical Medicine

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-Approximately half of all patients who die do so in hospital. Despite the advent of palliative care in the UK, there is evidence that the care that many patients receive in the final phase of their illness in hospital is poor. Building on a study of bereaved relatives' views of the information provided by an inner city hospital trust during an admission in which a patient died, this article explores the factors that may contribute to sub-optimal care for patients dying in hospital. IntroductionApproximately half of all patients who die in the UK do so in hospital. There is evidence to suggest that these patients have multiple symptoms, 1 and that the care many of these patients receive in the dying phase can be poor. Observational studies have shown that many dying patients do not receive basic comfort care (such as mouth care), are not given assistance eating and drinking, and that contact between healthcare professionals and patients is minimal. 2,3 Costello's recent observational study of patients dying on care of the elderly wards showed that nurses tended to focus on meeting patients' physical needs, while avoiding open communication about prognosis. In consequence, they rarely addressed important aspects of psychological and spiritual care. 3 Despite numerous studies that have highlighted the benefits of open communication at the end of life among cancer patients, 4 these needs are often unmet. [5][6][7] Recent studies using the views of bereaved carers (informants) to evaluate the care given to cancer patients in the last year of life confirm that poor communication at the end of life remains commonplace. 8,9Experience of dying in an inner London teaching hospitalIn 1998, a post-bereavement survey was conducted as part of a programme to identify and address the needs of patients dying in an inner London teaching hospital trust. This had arisen out of concerns regarding the care of this patient group. The methodology for this survey has previously been reported. 10 Of the 182 informants invited to participate in the study, 78 (43%) returned completed questionnaires. Thirty-six (20%) of those invited expressed a wish not to participate and 68 (37%) did not respond. There were no differences between the responders and non-responders. The majority (95%) of informants classified themselves as white; 54% were a spouse and 27% a son or daughter of the deceased. The most common cause of death was cardiovascular diseases (36%, including cerebrovasular disease); a further 20% had died from infective causes, predominantly bronchopneumonia; and in 13% the cause of death was cancer. There are several potential limitations to this study, including the low response rate and the lack of representation in informants from ethnic minority groups. In an area of high socio-economic deprivation, the views of informants who were unable to read or write in English may have been under-represented. Some doubts have been expressed about the reliability of such proxy reporting. 11-13 However, the research evidence suggest...

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“…When given accurate information, many patients who have expressed a desire for CPR change their minds. 1,2 Patients and families often believe that a DNR order means the medical team is giving up on them. This belief is an important and understandable factor in the A.S. case.…”

Section: Lesson 1 -The Need For Educationmentioning

confidence: 99%

The new ABCs: Airway, Breathing, and Court injunctions

Pauls

1999

CJEM

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RÉSUMÉ :Jusqu'à quel point la loi s'est-elle immiscée dans la pratique médicale? Les tribunaux peuvent-ils nous «obliger» à réanimer des patients lorsque nous jugeons l'intervention inutile? M. A.S., un homme âgé de 79 ans arrive difficilement à parler et à avaler à la suite de plusieurs AVC. Il a subi une trachéostomie et il ne peut exprimer ses propres souhaits. En 1998, lorsqu'il fut admis dans un hôpital de réadaptation, ses médecins rédigèrent un ordre de ne pas réanimer. Par la suite, comme l'ont rapporté les journaux, l'épouse de M. A.S. obtint une injonction «obligeant» le personnel de l'hôpital à administrer la réanimation dans le cas d'un arrêt cardiaque. Cette cause bien connue est présentement en litige devant les tribunaux du Manitoba. Qui a le dernier mot lorsque les médecins et les patients sont en désaccord? Quelles leçons doivent en tirer les médecins d'urgence? Le présent article discute des questions éthiques entourant la réanimation.

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The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation

Abstract: Older patients readily understand prognostic information, which influences their preferences with respect to CPR. Most do not want to undergo CPR once a clinician explains the probability of survival after the procedure.

Cited by 530 publications

References 43 publications

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

‘If only someone had told me…': A review of the care of patients dying in hospital

The new ABCs: Airway, Breathing, and Court injunctions

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