Friday, March 20, 2009
Age & Aging has a fascinating research paper on changing attitudes towards CPR in older patients in Ireland over 15 years. This study is a follow up to one done 15 years ago in the early 1990s which evaluated attitudes towards CPR in hospitalized but stable, older (over 65 years) patients who were approaching discharge (delirious, demented, and - curiously - depressed patients were excluded). The 1990s study was in a single hospital in Dublin; the current one, which deliberately used similar methods, was done in a couple hospitals in Galway, and involved 150 patients. Patients were read a description of CPR and then asked if they'd want it if they arrested in certain clinical scenarios (severe physical disability, severe dementia, terminal illness with a prognosis less than 6 months, critical illness with uncertain short term prognosis).
What was not disclosed to the patients, as far as I can tell from the paper, were likely outcomes of CPR. This strikes me as the most important bit of information in CPR decision-making, but who am I to say that? Anyway - the results between 1990s and today were dramatically different to the point of being shocking. The percent of patients wanting CPR in all clinically scenarios was dramatically increased in the contemporary cohort than the 1990s one. For instance - 74% said no to CPR in their current health state in 1990s vs. 6% today; for terminal illness - 96% vs 31%; for severe dementia 100% vs. 41%. There were some other findings and subanalyses (older patients in both cohorts were more likely to refuse CPR; many more 2000s patients thought doctors should discuss CPR with patients; most patients in both cohorts thought doctors should unilaterally be able to 'withhold' CPR in patients with poor prognoses).
Looking at the numbers, what's surprising to me is not so much the percentages of patients in the 2000s who didn't want CPR but it's the very low fraction of the 1990s cohort who didn't: 74% of those in their current state of health? Either a seismic shift has occurred in Ireland or something deeply flawed (research-wise) was occurring then. The authors opinion is that, in fact, a seismic shift has occurred in Ireland which explains the results. Interestingly they note that Ireland is generally wealthier than it was in the early 1990s (this study predates the current Global Economic Collapse of course) and wonder if that has anything to do with it (interesting because in the US increased wealth, or at least education which tends to track with wealth, is generally associated with relatively less interest in 'aggressive' end of life cares).
In addition they actually throw out that TV may be implicated as medical dramas have apparently become very popular in Ireland and they wonder if that has inflated patient expectations for CPR!
I would be personally very interested to see two things in follow up to this, although I know I won't. First is a similar study with a US/North American population to see if a similar trend has occurred although I doubt there was ever a US study which showed anything similar to the 1990s findings. Second would be to take the same group of patients and re-ask them the questions after being given survival-to-discharge data for in-hospital arrests - that would at least give us some semblance of what these patients would say when 'truly' (or at least 'more truly') informed...not that many real-life patients are given that information when having 'code status' discussions.
(Thanks to Dr. Robert Arnold for alerting me to this.)
Cotter, P., Simon, M., Quinn, C., & O'Keeffe, S. (2008). Changing attitudes to cardiopulmonary resuscitation in older people: a 15-year follow-up study Age and Ageing, 38 (2), 200-205 DOI: 10.1093/ageing/afn291