Monday, March 23, 2009

'State of the Science Fiction' the snappy title of a recent publication on public perception of resuscitation outcomes in Resuscitation. The data come from a survey of ~1800 people administered in Ohio & Pennsylvania in a 'variety of community settings' (airports, bus stations, and clinic waiting rooms). They don't give any further details as to how these people were found/screened; that said, there does not appear to be even an attempt to get at a random cross section of a population.

Median age of the subjects was 40 years, 55% were female, 17% African American, and 72% had education beyond high school (more than the US average). Respondents' mean estimate of survival with good outcomes (returned to the life the arrestee had before) from cardiac arrest (they asked about both in-community arrests and in-hospital ones) was 50%. As in 5-0. Not 1-5, which is a generous figure for this outcome (and actually is the approximate chance of survival-to-discharge after an in-hospital arrest; survival to baseline status is worse although less well defined in the literature; survival of an out-of hospital arrest is much lower).

They also inquired about decision-making about when to do CPR; 87% rated patient preference as important & only 54% rated physician prediction of outcome as important. To an extent, those who had more realistic expectations for resuscitation outcomes were less likely to endorse wanting it.

The most curious findings were about what resuscitation procedures subjects would be willing to undergo. Of those who said they themselves would want efforts to 'restart their heart' if they had an arrest, they went on to list (in lay-terminology) certain common aspects of CPR and asked them if having that done to them would be 'acceptable.' Many subjects then actually went on to say they wouldn't want these things: only 74% said they'd want chest compressions, 61% shocks, 54% IV medications, 48% endotracheal intubation, 42% mechanical ventilation, 31% a central line.

This, to me, is where the SciFi aspects of the paper really come out. It's no shock lay people don't understand likely outcomes of resuscitation - what's surprising to me is that these people then rejected in large numbers routine aspects of resuscitation, which makes one wonder just what the subjects thought resuscitation entailed. The phrasing in the questionnaire talks about arrests, and about 'restarting the heart;' most subjects generally thought this was a good idea, especially for themselves. But when asked if this happened to them, if they'd take a 'large IV in their groin or neck' 70% say that wouldn't be acceptable to them?

Given that just a little over a half of the subjects thought physician prediction of outcome was important for resuscitation decision making, then a good half of the subjects went about saying they wouldn't want endotracheal intubation, I'm reading this wondering if I've been thinking about 'code status' discussion incorrectly all these years. I've always thought the much-practiced 'gory description' approach in discussion CPR was misguided (e.g. 'we pound on your chest, break your ribs, stick this pipe down your throat, hook you up to a breathing machine, and stick central lines in you wherever we can find a big vein). Instead, the fundamental question is one of outcomes: if such procedures would restore someone to their previous state of health in a timely fashion then, well, who should care about the details - it's better than death (assuming the previous state of health was good/acceptable). Of course, it usually doesn't, and hardly ever does for otherwise dying patients, which is the whole point of not doing it in those situations, with the 'gory' details being just that (details). Thus, the main goal in having these discussions (at least in otherwise dying/poor prognosis patients), is to disclose the outcomes (and recommend alternative plans).

These data would suggest otherwise: screw the outcomes, focus on the gore, and people are going to say 'No thanks!'

Despite these data, I have a hard time believing that is actually a good idea. Ignoring the issues around subject selection (not random, not representative of any population, geographically limited)...and I think we can ignore them because it is likely that a truly random sample would have found generally similar figures...I wonder if one of the phenomena going on here is one to do with the youth and healthiness of the subjects. You get the sense that these people are saying "Sure restarting the heart is a good idea. Why wouldn't it be? I'd want my heart restarted if it stopped in the ER! Who wouldn't? Stick a tube down my throat? I don't know about that. That doesn't sound fun - no thanks."

In real-life, as we sit at the bedside of ill, suffering patients, afraid of death which they know is approaching, desperate for any way out - a femoral line or a little 'cardiac massage' can seem like a small price to pay to forestall death a while. For these patients, it's the unfortunate reality that we can't forestall death in that way (resuscitation) that is the 'message' that counts - that matters for 'decision-making.' That said, maybe I should not dismiss more detailed descriptions of what is actually involved (what I've glibly referred to above as the 'gore') as unimportant/unhelpful.

I'm curious as to how detailed, or even how frankly gory, others approach these conversations (ones in which the patient is dying, and your clear recommendation is not to attempt resuscitation due to dismal outcomes)?

ResearchBlogging.orgMARCO, C., & LARKIN, G. (2008). Cardiopulmonary resuscitation: Knowledge and opinions among the U.S. general public - State of the science-fiction Resuscitation, 79 (3), 490-498 DOI: 10.1016/j.resuscitation.2008.07.013

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