Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults

Abstract

Context. Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values. Objectives. To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent. Methods. Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states. Results. Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804). Conclusion. Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.

End-of-Life Care Preferences of Older Patients with Multimorbidity: A Mixed Methods Systematic Review

“…Of the 15 observational quantitative studies, five [ 38 , 39 , 40 , 45 , 47 ] were conducted in North America, seven [ 27 , 32 , 33 , 34 , 35 , 36 , 44 ] in Europe and three [ 28 , 31 , 43 ] in Asia. The studies were performed between 1992 and 2020 and mostly in an outpatient setting.…”

“…It included 121 patients with a mean age of 84 years, of which 84 were female. Nine studies assessed preferences in patients with multimorbidity without any indication of an index disease [ 28 , 29 , 38 , 39 , 40 , 42 , 45 ], while the remaining 13 studies assessed patients with index diseases associated with at least one other morbidity (i.e., cancer, cardiovascular disease, chronic heart failure, chronic obstructive pulmonary disease and ESRD). Response rates ranged from 43% to 100% of eligible patients, with a mean response rate of 76% (19).…”

“…The only quantitative non-randomized study [ 29 ] had low RoB. The quality of the 15 quantitative descriptive studies [ 27 , 28 , 31 , 32 , 33 , 34 , 35 , 36 , 38 , 39 , 40 , 43 , 44 , 45 , 47 ] varied, with eleven studies [ 27 , 31 , 32 , 33 , 34 , 35 , 36 , 38 , 39 , 40 , 44 ] scoring high because of a high participant non-response bias, three studies [ 31 , 40 , 44 ] not providing enough information to assess representativeness, and one study [ 31 ] not providing enough information to assess whether the employed measurements were appropriate. The three mixed methods studies [ 26 , 30 , 42 ] also scored low.…”

Cardiopulmonary Resuscitation Preferences of People Receiving Dialysis

“…60 , 61 Prior research in other populations suggests that patients are less likely to want to be resuscitated when they are informed about the expected outcome. 32 , 62 , 63 , 64 …”

“…For the analyses described herein, participants who indicated they would probably or definitely want CPR were classified as preferring CPR, whereas those who said they would probably or definitely not want CPR were classified as preferring not to be resuscitated (do not resuscitate [DNR]). 32 …”