Abstract
Whether the cardiopulmonary resuscitation (CPR) preferences of patients receiving dialysis align with their values and other aspects of end-of-life care is not known. To describe the CPR preferences of patients receiving dialysis and how these preferences are associated with their responses to questions about other aspects of end-of-life care. Cross-sectional survey study of a consecutive sample of patients receiving dialysis at 31 nonprofit dialysis facilities in 2 US metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 22, 2015, and October 2, 2018. Analyses for this article were conducted between December 2018 and April 2020. Participants were asked to respond to the question "If you had to decide right now, would you want CPR if your heart were to stop beating?" Those who indicated they would probably or definitely want CPR were categorized as preferring CPR. This study examined the association between preference for CPR and other treatment preferences, engagement in advance care planning, values, desired place of death, expectations about prognosis, symptoms, and palliative care needs. Of the 1434 individuals invited to complete the survey, 1009 agreed to participate, and 876 were included in the analytic cohort (61.1%). The final cohort had a mean (SD) age of 62.6 (14.0) years; 492 (56.2%) were men, and 528 (60.3%) were White individuals. Among 738 of 876 participants (84.2%) who indicated that they would definitely or probably want CPR (CPR group), 555 (75.2%) wanted mechanical ventilation vs 13 of 138 (9.4%) of those who did not want CPR (do not resuscitate [DNR] group) (P < .001). A total of 249 of 738 participants (33.7%) in the CPR group vs 84 of 138 (60.9%) in the DNR group had documented treatment preferences (P < .001). In terms of values about future care, 171 participants (23.2%) in the CPR group vs 5 of 138 (3.6%) in the DNR group valued life prolongation (P < .001); 320 in the CPR group (43.4%) vs 109 of 138 in the DNR group (79.0%) valued comfort (P < .001); and 247 participants (33.5%) in the CPR group vs 24 of 138 (17.4%) in the DNR group were unsure about their wishes for future care (P < .001). In the CPR group, 207 (28.0%) had thought about stopping dialysis vs 62 of 138 (44.9%) in the DNR group (P < .001), and 181 (24.5%) vs 58 of 138 (42.0%) had discussed stopping dialysis (P = .001). No statistically significant associations were observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs. The CPR preferences of patients receiving dialysis were associated with some, but not all, other aspects of end-of-life care. How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR preference. More work is needed to integrate discussions about code status with bigger picture conversations about patients' values, goals, and preferences for end-of-life care.
Highlights
People with end-stage kidney disease (ESKD) receiving maintenance dialysis have mortality rates of 15% to 20% per year.[1]
No statistically significant associations were observed between cardiopulmonary resuscitation (CPR) preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs
How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR
Summary
People with end-stage kidney disease (ESKD) receiving maintenance dialysis have mortality rates of 15% to 20% per year.[1] Compared with the general population, these patients are far more likely to die prematurely of a cardiac arrest.[2,3,4,5] Out-of-hospital sudden cardiac death occurs 20 times more often in people receiving dialysis than in the general population.[1,2,3,6] Less than 25% of patients who experience a cardiac arrest during dialysis treatment survive to hospital discharge, and only 8% to 15% survive more than 1 year after the arrest.[3,6,7,8,9,10] Most prior studies have shown that outcomes after in-hospital cardiac arrest are less favorable for these patients than for more broadly defined populations, with only one-half surviving beyond 5 months (compared with almost 3 years for the general population).[11,12] Patients receiving maintenance dialysis who survive a cardiac arrest in the hospital are more likely to be discharged to a skilled nursing facility compared with other survivors of cardiac arrest.[13]
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