“To Be or Not to Be”—Cardiopulmonary Resuscitation for Hospitalized People Who Have a Low Probability of Benefit: Qualitative Analysis of Semi-structured Interviews

Abstract

Purpose Our aim was to understand the decision making of patients in hospital who wanted cardiopulmonary resuscitation despite low probability of benefit. Methods We included patients admitted to general medical wards who had a low chance of surviving in-hospital cardiopulmonary resuscitation (CPR) and had an order in the chart to administer CPR. We developed an interview guide to explore participants’ decision-making process, sources of information, and emotions associated with this decision. Results We developed 3 themes from the data. 1) “Life is worth living . . . for now”: Participants describe their enjoyment of life and desire to carry on in their current state. 2) “Making sense of CPR outcomes”: Participants saw CPR outcomes as binary, either they live, or they die; deciding not to receive CPR means choosing death. Participants were optimistic they would survive CPR and cited personal experience and TV as information sources. 3) “Decision process”: Participants did not engage in shared decision making. Instead, they were asked a binary yes/no question with no reflection on their values or discussion about harms or benefits. Limitations The probability of successful CPR in our sample is unknown. Findings may be different in a population who is imminently dying but still requesting CPR. Conclusions Participants chose CPR because they perceived life as worth living and CPR as a chance worth taking. Participants did not want to be left in a severely debilitated state but did not have accurate information about this risk. Implications Decision making about CPR in-hospital can be improved if it is grounded in accurate risk understanding and the patient’s values and wishes.

Portuguese Advance Directives-a twist against futility? A cross sectional study

“…In a systematic review of nonbeneficial treatments in hospitals at the end-of-life, 13 that included 1,213,171 participants across 10 different countries, the most frequently reported situations were non-beneficial ICU admissions (10% prevalence), newly initiated or ongoing chemotherapy (33% prevalence), cardiorespiratory resuscitation for terminal patients (28,1% prevalence), death in the ICU and on a hospital ward, or after initiating aggressive treatment (58% prevalence), and nonbeneficial examinations in patients classified as "Do not resuscitate" (33%-50% prevalence). 13 The literature is scarce on research emphasizing patients who choose invasive treatments despite the low chance of benefitting them, 14 as we noticed in our trial results. Kobewka et al 14 analyzed the end-of-life decisions of 13 patients with advanced organ failure diseases or at high risk of death who requested CPR if their heart stopped.…”

“…13 The literature is scarce on research emphasizing patients who choose invasive treatments despite the low chance of benefitting them, 14 as we noticed in our trial results. Kobewka et al 14 analyzed the end-of-life decisions of 13 patients with advanced organ failure diseases or at high risk of death who requested CPR if their heart stopped. In this trial, all 13 patients had previously seen a decision-aid video regarding CPR, its benefits, and harms, and still chose to ask for resuscitation maneuvers.…”

“…The main reasons for their answers reflected a solid will to prolong life and the sense that refusing CPR meant choosing to die. Similar to this study, most participants lacked sufficient information on CPR and its consequences, and still, they defended this choice as essential and “worth a try.” 14 The authors also highlight the high risk of discordance between the patient’s preferences and the performed treatments, classifying it as a seriously wrong event that must be prevented.…”