Tuesday, June 23, 2009
Journal of Medical Ethics has an article about hospitalized patients' understanding of and attitudes towards code status discussions (see also this blog post about a similar study). The study involved interviewing ~140 newly hospitalized patients (median age 48 years, 92% white, over 80% had were expected to live more than 2 years according to their treating physician) about their understanding of and attitudes toward CPR, code status orders, etc. Among other things they were asked what they thought the survival was for in-hospital arrests; they were then told it was about 15% survival to discharge and were asked if that changed their preferences for wanting CPR, etc.
Patients had very poor understanding of CPR and its outcomes. About 30% of patients recalled having a discussion about code status during the hospitalization. Most patients noted that they thought they knew what CPR meant and entailed. 68% knew it meant chest compressions however only 27% knew it could involve defibrillation and only 7% mechanical ventilation. About 90% of patients (including the oldest group) said they would want all 3 (of note when they describe the situation they describe it as one in which 'you are dying').
Overall patients estimated survival to discharge after an in-hospital arrest to be 60%. After being told actual expected survival is about 15%, 9 patients said they were less interested in CPR. After being told expected survival to discharge with 'good brain function' was about 7%, 25 patients said they were less interested in receiving CPR.
8% of patients had code statuses which did not reflect their stated preferences; 2/3 of whom were 'full code' and didn't want to be. They noted that over 80% of patients said they thought it was good to talk about CPR outcomes. Only a few percent said talking about CPR made them uncomfortable. About a quarter of patients said they had living wills/advance directives; less than 5% of patients had them in their chart.
While they did collect data about physician estimation of prognosis, they do not mention if they compared that with patient preferences or anything else.
This is another solid reminder of how little patients actually understand about CPR - both its 'methods' and outcomes, and that we should take nothing for granted when discussing it. It also indicates that discussion of outcomes does change some patients minds, although a relatively small percent overall (fewer than this landmark study, although that one involved a much older patient population, and asked questions in the context of a patient's long-term survival as well). The fact that these were young and relatively 'healthy' patients probably is what leads to these results, especially compared to the older study: if you are 48 years old, expecting another 20-40 years of life, a 15% chance sounds pretty good. If you have a progressive, life-limiting disease, with a short overall survival (e.g. likely less than a year) the benefit:burden profile looks much different (aside from the reality that in those patients 15% is probably a generous figure).