Monday, March 23, 2009
'State of the Science Fiction'
...is 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)?
MARCO, 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
5 Responses to “'State of the Science Fiction'”
March 24, 2009
As an intake nurse for a hospice agency, I have this discussion with patients and families at least once a week. I always use common sense to guide me how far to push to subject. It's usually pretty clear to me when patients and families don't want to discuss resuscitation at all or don't want to be told the risks involved.
For those patient who I feel are ready for a discussion or who are simply naive to what resuscitation involves, I give them the gory details in as nice a way as possible. I tell them that it involves chest compressions which can break ribs and puncture lungs, electric shocks, intubation with a tube inserted in the throat and into the lungs, and always transport to a hospital. I explain that most people feel this is reasonable if they are otherwise healthy but for someone with a life-threatening illness or who is clearly dying already, the risks just aren't worth taking. I also point out that resuscitation doesn't mesh with a goal for a peaceful and dignified death.
I've been told I'm a wonderful DNR salesperson but I'm really just delivering the facts and the facts are usually enough to help people make the best decision.
March 28, 2009
My script to patients about CPR:
"If and when you become very ill, and your illness progresses to the point that your heart stops beating or you stop breathing on your own, have you thought about what interventions you would or would not like to receive in that extreme situation? Some people have strong feelings about these things, and as your doctor, I want to know your preferences so I can honor your wishes and provide the best medical care possible. For example, would you want to receive manual chest compressions [here I mime them on myself], electric shocks to the heart [mime paddles to chest], and would you want a tube put in your throat and to be put on a breathing machine? The reason I ask is that I am obligated to perform these invasive measures unless you tell me otherwise, any many people prefer not to receive these measures because of their low chance of success. I'm not trying to push you in one direction or another, I simply want to know your wishes, and I want to be sure you have the best information to be able to make an informed decision. You don't have to tell me today, it's OK if you want to first talk to family or someone else that you trust. What questions do you have?"
I find this script can apply to almost all situations, whether I know the patient well or I've just met them.
David Fisher MD
Advocate Medical Group
Advocate Hospice
Chicago
March 29, 2009
Drew,
I don’t have access to the full-text, but here’s my take. Participants were overly optimistic in their assessment of survival likelihood. Amongst those patients who wished for an attempt to restart their heart, many expressed a desire to avoid the individual procedures that go along with resuscitation. This represents a striking disconnect, as you say. What percentage of respondents expressed a desire for a resuscitative attempt? It would be interesting to provide those respondents with the dismal statistics about survival of out-of-hospital resuscitation and see how many change their mind based on those statistics. Would there be any correlation between those that change their minds and those that didn’t want the individual procedures? Some respondents might be disinclined to change their answers because they had already committed to resuscitation (commitment bias). Perhaps one would need to repeat the survey in a similar population- this time providing the dismal statistics upfront. There could be a commitment bias in real-life physician-patient conversations about this topic, as well. (Perhaps the patient has told physician after physician that they wish to have these measures based on misinformation about survival likelihood. Then, another physician informs the patient of the low benefit, but the patient is already committed to his previous answer.)
I tend to avoid details about the procedures and typically advise learners to focus on the lack of benefit (with perhaps a general statement about the burdens). This seems easiest to do when the goals of care are clearly in line with avoidance of resuscitation. I will occasionally go into more details, but usually I’ll focus on the day to day issues that likely cause suffering in the ICU for patients and families, especially being unable to communicate easily. I’ll usually combine that with a reiterated prediction of survival to hospital discharge. I’m not sure if I could explain how I decide when to provide gory details.
Lyle Fettig
April 03, 2009
Angela, David, Lyle thanks for your comments. David I use somewhat similar language to yours, however if I think that resuscitative efforts are not indicated I usually lead off with that, after an explanation of what I'm talking about: bring it up (as a rule, after i've had some conversation about overall prognosis/big picture and preferably goals); explain it; make my recommendation; ask what they think; answer questions; etc.
Lyle that's a fascinating point about committment bias and you've got to wonder: do you observe it (or wonder if you're observing it) clinically? I too am not so sure as to why exactly I start talking about the gory details: certainly if patients/family members have personal experience with it (themselves, witnessing it for another) and bring it up I address it. I was thinking back to a case I had as a resident in which I resuscitated someone; it went well; the next day she woke up and said 'You know doc I don't think I've felt this good in years!' (I think it was actually all the inotropes she had received.) For her, undergoing CPR was an entirely pleasurable experience, at least as far as she remembers the experience: that for me kinda sealed the fact that the issue is one of outcomes/benefit/lack of benefit and not the details. Hell
I'd get me some CPR if it would make me feel that good....
April 03, 2009
Regarding commitment bias, I'm curious if we observe it, but not at all sure. I do observe that there are some patients/families that have been asked about code status so many times that once I speak with them, their answer is codified, so to speak. Some rare patients/families will even anticipate the conversation and preemptively state, "If you're here to talk to me about code status...I can already tell you what I/we want." I wouldn't suggest that this is a commitment bias, but probably rather a firmly held preference. However, perhaps the preference becomes more firm (almost reactionary, perhaps) the more they are approached about it.
I've never met someone that felt better one day after CPR. Order some of that up for me as well...
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