Preferences For Cardiopulmonary Resuscitation Research Articles

Associations between Present-on-Admission Do-Not-Resuscitate Orders and Short-Term Outcomes in Patients with Pneumonia.

Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia. This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation. Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%). Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.

Overestimation of Survival Rates of Cardiopulmonary Resuscitation Is Associated with Higher Preferences to Be Resuscitated: Evidence from a National Survey of Older Adults in Switzerland.

Many widely used advance directives templates include direct questions on individuals' preferences for cardiopulmonary resuscitation (CPR) in case of decision-making incapacity during medical emergencies. However, as knowledge of the survival rates of CPR is often limited, individuals' advance decisions on CPR may be poorly aligned with their preferences if false beliefs about the survival rates of CPR shape stated preferences for CPR. We analyzed nationally representative data from 1,469 adults aged 58+ y who responded to wave 8 (2019/2020) of the Swiss version of the Survey on Health, Ageing, and Retirement in Europe (SHARE) to assess the partial association between knowledge of CPR survival rates and stated preferences for CPR using multivariable probit regression models that adjust for social, health, and regional characteristics. Knowledge of CPR survival rates was assessed by asking how likely it is in general in Switzerland for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital. Preferences for CPR were measured by asking respondents if they would wish to be resuscitated in case of cardiac arrest. Only 9.3% of respondents correctly assessed the chances for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital, while 65.2% indicated a preference to be resuscitated in case of a cardiac arrest. Respondents who correctly assessed CPR survival were significantly more likely to wish not to be resuscitated (average marginal effect: 0.18, P < 0.001). Reducing misconceptions concerning the survival rates of CPR could change older adults' preferences for CPR and make them more likely to forgo such treatments. Many older adults in Switzerland overestimate the survival rates of cardiopulmonary resuscitation (CPR).The study reveals that individuals with accurate knowledge of CPR survival rates are more likely to refuse resuscitation in case of cardiac arrest.Overestimation of CPR survival rates may lead to a mismatch between individuals' preferences for CPR and their actual end-of-life care decisions.Improving the general population's knowledge of CPR survival rates is crucial to ensure informed decision making and effective advance care planning.

Older adults’ medical preferences for the end of life: a cross-sectional population-based survey in Switzerland

ObjectivesMedical decision-making at the end of life is common and should be as patient-centred as possible. Our study investigates older adults’ preferences towards three medical treatments that are frequently included...

#4621 TREATMENT PREFERENCES TO SERIOUS ILLNESS IN PATIENTS RECEIVING PERITONEAL DIALYSIS

Abstract Background and Aims People with end-stage kidney disease receiving maintenance dialysis are more likely to receive intensive pattern of end-of-life care than those with other severe illness. It's important to understand the preferences to cardiopulmonary resuscitation (CPR) and other end-of-life care. However, no prior studies have investigated patients receiving peritoneal dialysis. This study aimed to explore the preference to CPR and patterns of end-of-life care in patient receiving peritoneal dialysis (PD), which had not been specifically investigated in the literature. Method This cross-sectional study of patients receiving PD was conducted in the National Taiwan University Hospital between Dec. 2021, and Mar. 2022. Patients were enrolled if they were 20 years or older, sufficiently fluent to complete surveys and cognitively able to provide written informed consent and had received maintenance peritoneal dialysis for at least 3 months. Enrollee were asked to the Chinese version of Physician Orders for Life-Sustaining Treatment questionnaire. Results Among 400 eligible patients, 364 (91%) responded to the questionnaire. The average age was 55.5 years; 50.3% were men. Among the 364 responders, 73.6% selected do not attempt resuscitation (DNR) and 26.4% preferred CPR. Multivariate logistic analysis revealed that age (OR = 0.96, 95% CI 0.94-0.98), male (OR = 2.44, 95% CI 1.45-4.1) and residual kidney Kt/V (OR = 2.45 95% CI 1.24-4.82) were associated with CPR. If they are facing on serious illness, 47.5% of participants prefer to “Focus on comfort”, 28.6% choose “try treatments, but do not suffer” and 23.9% request “live as long as possible”. Furthermore, 51.4% of participants selected “No artificial nutrient support” in the end of life and 87.1% select “comfort care” as their first priority. Paradoxically, only 13.5% of the patients who preferred CPR took “staying alive” as their first priority, while 71.9% focused on “comfort care”. Conclusion Around 75% of PD patients selected DNR when cardiopulmonary arrest. Age, gender, residual Kt/V were important factors associated with CPR preference. Most patients preferred supportive pattern of end-of-life care. Integrating patients' treatment preference to serious illness and values and goals of end-of-life care in shared decision making is important for patients receiving dialysis.

Resuscitation preferences of older acutely admitted medical and mentally competent patients with one and six months follow-up

AimDetermining patients’ cardiopulmonary resuscitation (CPR) preferences in the emergency department (ED) is common practice but the stability of these preferences and their recollection by patients has been questioned. Therefore, this study assessed the stability and recall of CPR preferences of older patients at and following ED discharge. MethodsThis survey-based cohort study was conducted between February and September 2020 at three EDs in Denmark. It consecutively asked mentally competent patients aged 65 years or older who were admitted to hospital through the ED and then one and six months later “In your current state of health, do you wish that physicians should try to intervene if your heart stops beating?” Possible responses were confined to “definitely yes”, “definitely no”, “uncertain”, and “prefer not to answer”. ResultsIn total, 3688 patients admitted to hospital via the ED patients were screened, 1766 were eligible and 491 (27.8%) were included: median age was 76 (IQR 71–82) years, and 257 (52.3%) were men. One third of patients who expressed definite yes or no preferences in ED had changed their preference at one month follow-up. Only 90 (27.4%) and 94 (35.7%) patients recalled their preferences at one and six months follow-up, respectively. Conclusion and RelevanceIn this study, one-in-three older ED patients who initially expressed definite resuscitation preferences had changed their minds at one month follow-up. Preferences were more stable at six months but only a minority were able to recall their preferences.

Taiwanese Older Adults Prefer to Use Antibiotics and Intravenous Infusion at the End of Life based on a Cartoon Version of the Life Support Preferences Questionnaire.

Asians believe discussing death-related topics is inauspicious and may bring bad luck. It is critical to explore the end-of-life care preferences of the Asian elderly with less-threatening tools. The study examined older adults' preferences regarding end-of-life treatments by applying a cartoon version of the Life Support Preferences Questionnaire (LSPQ). A cross-sectional survey was conducted to understand older adults' preferences for end-of-life treatments. A total of 342 older adults participated in the study, comprising 268 elderly patients from a veterans hospital located in northern Taiwan and 74 elderly family members of the patients. Regardless of scenario, cardiopulmonary resuscitation (CPR) had the lowest score, indicating that older adults considered it a less desirable medical treatment. By contrast, antibiotics and intravenous infusions had the highest scores, indicating that older adults tended to prefer them. End-of-life care preferences were significantly different in genders. CPR and surgical preferences of older adults differed significantly with education level. Different demographic characteristics had different end-of-life treatment preferences, and future research may develop advance care planning programs for different attributes. This cartoon version of the LSPQ can help healthcare professionals to understand older adults' preferences for end-of-life care and warrants further empirical research.

AWARENESS OF PARTNER PREFERENCES FOR END-OF-LIFE ASPECTS AND TREATMENTS IN OLDER ADULT COUPLES

Abstract Surrogate medical decision-making at the end of life is common and the patient’s partner is often the person who must make these critical decisions. The challenge of surrogate medical decision-making is to make decisions that best fit the patient's wishes. This study investigates how accurately older adult couples assess each other’s preferences for eleven end-of-life aspects and three medical treatments in a nationally representative sample of adults aged 58 and over living in Switzerland (N=573). The contribution of factors including end-of-life (EOL) discussion and care planning, self-rated knowledge of partner preferences, and EOL preferences homogamy in scoring higher in accurately assessing partner’s preferences for the end of life is examined. Weighted proportions, assessment accuracy scores and ordinary least squares regressions controlled for individuals’ characteristics are calculated. Results show that 44% of respondents accurately assessed their partners’ preferences for aspects related to medical, psychosocial, anticipatory and burden concerns at end of life, and 62% correctly predicted the preferences for cardiopulmonary resuscitation, life-prolonging measures, and palliative sedation. Respondents whose partner discussed their EOL preferences with them, completed an advance directive, designated them as their healthcare proxy, as well as respondents reporting very/rather good knowledge of their partners’ EOL preferences were more likely to have a higher accuracy score for their partners’ EOL preferences. Being a couple is not enough to assess one’s partner’s EOL preferences correctly. Communication about EOL wishes among the couple and individual EOL care planning should be encouraged, as both improve the assessment accuracy of partners’ EOL preferences.

CPR-Directive Conversations in the Emergency Department: The Opinion of Elderly Patients

Background: The average age of patients admitted to the emergency department (ED) continues to rise. Many face difficult discussions about cardiopulmonary resuscitation (CPR) and end-of-life decisions. Objectives: This study aimed to determine which healthcare professionals elderly patients admitted via the ED preferred to discuss their CPR-directive with and their opinion about the ED as a setting for discussing their CPR-directive. Methods: A mixed-methods study with an explanatory sequential design was conducted. A questionnaire was administered to 100 patients >65 years of age admitted to nursing wards via the ED that had a CPR-directive conversation during admission 24-48 hours earlier. Patients who indicated that they preferred to discuss their CPR-directive conversation with a physician working in the ED were invited for follow-up semi-structured interviews. Results: General practitioners (GP) were the most preferred healthcare professionals for a conversation about CPR-directives (64%). However, physicians working in the ED were the second most preferred medical professionals (51%) together with medical specialists (51%). Only 6% of patients did not consider a physician in the ED as a suitable option for these conversations. Interviewed patients saw a physician consultation in the ED as an opportunity to: 1) check and update their CPR-directive, 2) get information about the content and consequences of CPR considering their current health status, and 3) prevent the use of undesired medical treatment during admission. Conclusions: Although GPs were the most preferred healthcare professionals with whom to discuss CPR preferences, an unexpectedly large proportion of the investigated population preferred to discuss their choices with a physician working in the ED. These patients considered these discussions to be a crucial part of patient-centered healthcare.

Family Members' Understanding of the End-of-Life Wishes of People Undergoing Maintenance Dialysis.

People receiving maintenance dialysis must often rely on family members and other close persons to make critical treatment decisions toward the end of life. Contemporary data on family members' understanding of the end-of-life wishes of members of this population are lacking. Among 172 family members of people undergoing maintenance dialysis, we ascertained their level of involvement in the patient's care and prior discussions about care preferences. We also compared patient and family member responses to questions about end-of-life care using percentage agreement and the κ-statistic. The mean (SD) age of the 172 enrolled family members was 55 (±17) years, 136 (79%) were women, and 43 (25%) were Black individuals. Sixty-seven (39%) family members were spouses or partners of enrolled patients. A total of 137 (80%) family members had spoken with the patient about whom they would want to make medical decisions, 108 (63%) had spoken with the patient about their treatment preferences, 47 (27%) had spoken with the patient about stopping dialysis, and 56 (33%) had spoken with the patient about hospice. Agreement between patient and family member responses was highest for the question about whether the patient would want cardiopulmonary resuscitation (percentage agreement 83%, κ=0.31), and was substantially lower for questions about a range of other aspects of end-of-life care, including preference for mechanical ventilation (62%, 0.21), values around life prolongation versus comfort (45%, 0.13), preferred place of death (58%, 0.07), preferred decisional role (54%, 0.15), and prognostic expectations (38%, 0.15). Most surveyed family members reported they had spoken with the patient about their end-of-life preferences but not about stopping dialysis or hospice. Although family members had a fair understanding of patients' cardiopulmonary resuscitation preferences, most lacked a detailed understanding of their perspectives on other aspects of end-of-life care.

Goals of care discussions in acute hospital admissions – Qualitative description of perspectives from patients, family and their doctors

ObjectiveGoals of care discussions guide care for hospital inpatients at risk of deterioration. We aimed to explore patient and family experience of goals of care during the first 72 h of admission along with their doctor’s perspective. MethodsA qualitative descriptive study. Patients, family and doctors who participated in a goals of care discussion during an acute hospital admission at an Australian tertiary teaching hospital were interviewed in 2019. ResultsMany participants found goals of care discussions appropriate and reported understanding. However, communication was commonly procedure-focused, with questioning about preferences for cardiopulmonary resuscitation and intubation. Some considered the discussion as inapplicable to their state of health, and occasionally surprising. Participants commonly related goals of care with death, and without context, this led to fear of abandonment. Previous experience with end of life care influenced decision-making. Preference for family presence was clear. ConclusionsThis study identifies deficiencies in goals of care communication in the acute hospital setting. Discussions are life-saving-procedure focused, leading to poor understanding and potentially distress, and jeopardising patient-centred care. Practice implicationsAssessment of patient values and clear communication on the aims of goals of care discussions is essential to optimise patient and institutional outcomes. Clinicians should consider environment and invite family participation.

Engaging in resuscitation status conversations in psychiatry: A qualitative study of nurses' perspectives.

WHAT IS KNOWN ON THE SUBJECT?: Discussion and documentation of a patient's resuscitation status are essential aspects of any hospital admission, and yet, they seldomly occur in psychiatry. Nurses play an important role in resuscitation status determination by being an information broker, supporter and advocate. Persons with mental illness may be competent to engage in the determination of their resuscitation status and deserve the same respect and autonomy as other patients during this process. There are no published qualitative studies exploring healthcare providers experiences in initiating resuscitation status conversations in the psychiatric setting. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: An in-depth qualitative understanding of the complexity of resuscitation status determination in psychiatry. The shared experiences of nurses enacting their role in resuscitation status determination with patients admitted to psychiatry. The challenges of implementing a 'one-size fits all' approach to resuscitation status policies, and the ways in which depression and/or suicidal ideation influence the process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Role clarity and improved communication between providers about resuscitation status determination in psychiatry are needed. Hospital policies for resuscitation status determination must account for the psychiatric context to ensure patients' goals of care are known and upheld. Nurses working in psychiatry should initiate and more readily engage in resuscitation status conversations. ABSTRACT: Introduction Patients with mental illness experience stigma and marginalization, which affects the quality of their health care. In most settings, end-of-life decisions, including goals of care, must be discussed with all patients upon hospital admission, including determining cardiopulmonary resuscitation preferences in the event of a medical emergency. Despite this requirement, these conversations do not routinely occur in inpatient psychiatry. By default, patients become a 'full code status', mandating life-sustaining interventions. Aim To explore how and why resuscitation status conversations occur, or do not occur, in inpatient psychiatry from the perspectives of healthcare providers. Method Qualitative descriptive study using focus groups with nurses working in psychiatry. Results Nurses' experiences with initiating and engaging in resuscitation status conversations related to Working in Psychiatry, which represents the current practices and the participants' views of the nursing role; Caring for Psychiatric Patients, which describes how fluctuating competency and suicidality influence determination; and The Influence of Physical Health Status, which details how differences in physical health status affect how healthcare providers engage in resuscitation status determination. Discussion Although the importance of completing resuscitation status conversations with patients admitted to psychiatry was expressed by participants, they seldomly occur. There is ambiguity about when and how to determine patient wishes. Implications for practice Tailored strategies are needed to ensure patients' rights to self-determination are upheld when they are admitted to psychiatry. Nurses working in this setting would benefit from education, training and support to adequately initiate and engage in these conversations.

POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care

POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. Programs based on the POLST paradigm are used in virtually every state under names that include POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), and these forms are used in the care of hundreds of thousands of geriatric patients every year. Although POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition, some nursing homes and residential care settings use POLST to document CPR preferences for all residents, resulting in potentially inappropriate use with patients who are ineligible because they are too healthy. This article focuses on reasons that POLST is used as a default code status order form, the risks associated with this practice, and recommendations for nursing homes to implement appropriate use of POLST.

Association of Race with End-of-Life Treatment Preferences in Older Adults with Cancer Receiving Outpatient Palliative Care.

Background: End-of-life discussions and documentation of preferences are especially important for older cancer patients who are at high risk of morbidity and mortality. Objective: To evaluate influence of demographic factors such as religiosity, education, income, race, and ethnicity on treatment preferences for end-of-life care. Methods: A retrospective observational study was performed on baseline data from a multisite randomized clinical trial of Dignity Therapy in 308 older cancer patients who were receiving outpatient palliative care (PC). Interviews addressed end-of-life treatment preferences, religion, religiosity and spirituality, and awareness of prognosis. End-of-life treatment preferences for care were examined, including preferences for general treatment, cardiopulmonary resuscitation (CPR), and mechanical ventilation (MV). Bivariate associations and multiple logistic regression analysis of treatment preferences with demographic and other baseline variables were conducted. Results: Our regression models demonstrated that race was a significant predictor for CPR preference and preferences for MV, although not for general treatment goals. Minority patients were more likely to want CPR and MV than whites. Men were more likely to opt for MV, although not for CPR or overall aggressive treatment, than women. Higher level of education was a significant predictor for preferences for less aggressive care at the end-of-life but not for CPR or MV. Higher level of terminal illness awareness was also a significant predictor for preferences for CPR, but not MV or aggressive care at the end-of-life. Discussion: Race was significantly associated with all three markers for aggressive care in bivariate analysis and with two out of three markers in multiple regression analysis, with minorities preferring aggressive care and whites preferring less aggressive care. Contrary to our hypothesis, income was not significantly associated with treatment preferences, whereas religion was significantly associated with all markers for aggressive care in bivariate models, but not in multiple regression models. Clinical Trial Registration Number NCT03209440.

'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions.

BackgroundDiscussing patient preferences for cardio‐pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making.ObjectiveThe objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations.MethodWe recorded forty‐three physician‐patient admission interviews taking place in a hospital in French‐speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English.ResultsMean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers.Discussion and conclusionsThe scarcity and simplicity of CPR explanations highlight a reluctance to have in‐depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient‐centred care.Patient contributionPatients were involved in the data collection stage of the study.

Are We Getting What We Really Want? A Systematic Review of Concordance Between Physician Orders for Life-Sustaining Treatment (POLST) Documentation and Subsequent Care Delivered at End-of-Life.

Physician Orders for Life-Sustaining Treatments (POLST) is an advance care planning (ACP) tool that is designed to facilitate End-of-Life (EoL) care discussions between a medical provider and a terminally ill patient. It is often used as a tool to translate care wishes into a medical order, which can be honored across healthcare settings. With an increased utilization of the POLST paradigm in various healthcare settings along with continued dissemination across the nation, it is critical to examine whether documented wishes on POLST are concordant with subsequent care delivered. Purpose of this article was to examine concordance rate between POLST and subsequent care delivered in any care settings and communities. Systematic review. Of 1,406 articles identified, 10 articles met inclusion criteria. Together, included studies represent 5,688 POLST forms reviewed from individuals residing in a total of 126 nursing care facilities, 9 elderly care centers, 4 community settings, and 2 hospitals. Preference for cardiopulmonary resuscitation and actual delivery/ withholding of resuscitation was the most observed intervention in study of concordance (n = 8). It is also where highest concordance rate (97.5%) was reported. Seven studies compared care provided during EoL and the level of medical intervention requested on POLST forms (91.17% concordance). Preference to use artificial nutrition/ hydration, and actual delivery was 93.0% (n = 4 studies), and antibiotics use preference and delivery was 96.5% (reported in 4 studies). Published literature evidence suggests that EoL care wishes documented on POLST forms were largely concordant with subsequent care delivered. Additional research is needed to evaluate concordance between POLST documentation and care received among POLST users, who experienced multiple care transitions across healthcare settings, or across state during EoL care journey.

Cardiopulmonary Resuscitation Preferences of People Receiving Dialysis

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.

Perspectives of emergency department attendees on outcomes of resuscitation efforts: origins and impact on cardiopulmonary resuscitation preference

BackgroundPrevious studies have shown that individuals overestimate the success of cardiopulmonary resuscitation (CPR) while underestimating its morbidity. Although perceptions of CPR success affect medical care in the emergency department (ED),...

Effects of Brief Nurse Advance Care Planning Intervention with Visual Materials on Goal-of-Care Preference of Japanese Elderly Patients with Chronic Disease: A Pilot Randomized-Controlled Trial.

Purpose: Advance care planning is an important component of quality palliative care. In Asian countries, few randomized clinical trials have been reported. This pilot randomized-controlled trial examined the effects of brief nurse intervention with visual materials on the goal-of-care preference, cardiopulmonary resuscitation (CPR) preference, and designation of a health care proxy. Methods: This randomized clinical trial was performed from January to February 2018 on elderly Japanese patients with chronic disease. The patients were randomly assigned to a control group (brief nurse intervention using verbal descriptions) or intervention group (using visual materials). The primary endpoint was goal-of-care preference, and secondary outcomes included the following: (1) CPR preference, (2) presence of a designated health care proxy, (3) knowledge of CPR, and (4) readiness for advance care planning. Outcome measures were obtained at baseline and just after completion of the intervention. Results: A total of 220 patients were enrolled (117 in the intervention group and 103 in the control group). All patients completed post-intervention measurement. There was no significant difference between the groups in any of the outcome measures, while <5% of the participants wanted life-prolonging care as the goal of care at the baseline. Before/after comparisons indicated that, in both groups, the number of participants who designated a health care proxy significantly increased (29% to 65% vs. 22% to 52%, respectively; p < 0.001 each); and the knowledge and readiness scores significantly increased. Moreover, there was a significant increase in the number of patients who did not want CPR (55% to 67% with a terminal condition, p = 0.003; 67% to 80% with a bedridden condition, p < 0.001) in the intervention group. Conclusions: Brief nurse intervention increased documentation of a patient-designated health care proxy and improved the knowledge of CPR and patient readiness. Visual materials might help patients to imagine the actual situation regarding CPR.

Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans' Care Preferences.

On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set. Evaluate the first 7months of LSTDI implementation and identify predictors of LST template completion. Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score. All veterans with VA utilization between July 1, 2018, and January 31, 2019. Completed LST templates, goals and LST preferences, and predictors of documentation. LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation. LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs.

PC-FACS

PC-FACS