Perspectives on cardiopulmonary resuscitation in the frail population: a scoping review

Taubert M., Baker J.I.

In this article, the authors look at the concept of harm in relation to cardiopulmonary resuscitation (CPR) and ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) discussions. For patients with incurable, advancing illness, having discussions to ascertain their views about CPR, and suggesting and instituting advance care planning measures such as ‘Do Not Attempt CPR’ forms, is becoming standard practice in medical settings. Here, we discuss the concept of harm, and how contemporary DNACPR discussions, policies, laws and forms are changing such approaches. Definitions of harm, misconceptions of harm in relation to the procedure of CPR, six key areas in which harm can be considered in the context of CPR, and how harm can be looked at in relation to discussions about DNACPR, are presented.

Peters M.D., Marnie C., Tricco A.C., Pollock D., Munn Z., Alexander L., McInerney P., Godfrey C.M., Khalil H.

Fan S., Hsieh J.

Physicians have a responsibility to discuss do-not-resuscitate (DNR) decisions and end-of-life (EOL) care with patients and family members. The aim of this study was to explore the DNR and EOL care discussion experience among physicians in Taiwan. A qualitative study was conducted with 16 physicians recruited from the departments of hospice care, surgery, internal medicine, emergency, and the intensive care unit. The interview guidelines included their DNR experience and process and EOL care discussions, as well as their concerns, difficulties, or worries in discussions. Thematic analysis was used to analyze data. Four themes were identified. First, family members had multiple roles in the decision process. Second, the characteristics of the units, including time urgency and relationships with patients and family members, influenced physicians’ work. Third, the process included preparation, exploration, information delivery, barrier solution, and execution. Fourth, physicians shared reflections on their ability and the conflicts between law, medical professionals, and the best interests of patients. Physicians must consider not only patients’ but also family members’ opinions and surmount several barriers in decision-making. They also experienced negative and positive impacts from these discussions.

Myers A.L., Matthias M.S.

CONTEXT As many as one-quarter of all residents in nursing facilities have cardiopulmonary resuscitation (CPR) as a documented choice in the medical record, despite the likelihood of limited medical benefit in this setting. OBJECTIVES The aim of this study was to understand the perspectives of healthcare providers and nursing facility residents regarding CPR decisions. METHODS We used qualitative interviews to examine the perspectives of residents with a documented decision for CPR in the medical record. We then compared residents' views with those of healthcare providers who routinely conduct advance care planning (ACP) conversations in the nursing facility setting. RESULTS Five themes emerged from the interviews: (a) Resident versus Provider Concerns, (b) Offering Information versus Avoidance, (c) Lack of Understanding of CPR, (d) Lack of Awareness, and (e) 'Don't Keep Me on Machines'. Residents held misconceptions about CPR and/or exhibited an overall poor understanding of the relationship between their own health status and the likelihood of a successful CPR attempt. Although healthcare providers offer information and health education in an attempt to address knowledge gaps, these efforts are not always successful or even accepted by residents. Resident viewpoints and priorities differed from healthcare providers in ways that affected communication about CPR. CONCLUSIONS Unrecognised differences in perceptions between providers and residents affect key aspects of ACP communication that can impact CPR decision-making. The concerns and priorities of institutionalized older adults may differ from those of healthcare providers, creating challenges for engaging some residents in ACP. IMPLICATIONS FOR PRACTICE ACP communication models and training should be designed not only to explore nursing facility residents' goals, values, and preferences, but also to elicit any underlying differences in perceptions that may affect communication. Healthcare providers can identifying the primary concerns of residents and assist them with integrating or reframing these issues as a part of ACP discussions.

Kiguchi T., Okubo M., Nishiyama C., Maconochie I., Ong M.E., Kern K.B., Wyckoff M.H., McNally B., Christensen E.F., Tjelmeland I., Herlitz J., Perkins G.D., Booth S., Finn J., Shahidah N., et. al.

Background Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries. Methods We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey. Results Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0–97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1–79.0% in all registries and 2.0–37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1–20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8–18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%. Conclusion This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.

Druwé P., Benoit D.D., Monsieurs K.G., Gagg J., Nakahara S., Alpert E.A., Schuppen H., Élő G., Huybrechts S.A., Mpotos N., Joly L., Xanthos T., Roessler M., Paal P., Cocchi M.N., et. al.

OBJECTIVES To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE). SETTING Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the “appropriate” subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the “uncertain” subgroup, and 2 of 107 (1.9%) in the “inappropriate” subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39–45, 2019

Burden E., Pollock L., Paget C.

ObjectivesSuccess of in-hospital resuscitation decreases with age; however, national data show that 11.3% of patients over 80 years survive to discharge. There are few published qualitative data about the quality of life for these patients postsuccessful resuscitation. We aimed to investigate postresuscitation quality of life in patients over the age of 80 through a series of case studies.MethodsAll patients over the age of 80 years, who received cardiopulmonary resuscitation (CPR) at our district general hospital in 2015–2016, were included. Success of resuscitation, survival at day 1 and to discharge were recorded. For patients who survived to 1 day and beyond, case reports were written to create individual patient stories.Results47 patients over the age of 80 years received CPR at Musgrove Park Hospital over a 2-year period. Five (10.6%) survived to discharge. Of those surviving to discharge, two had substantial functional decline, requiring discharge to nursing homes having previously been independent. Of the five families/patients who commented on their experience, only one expressed a positive view. When discussed, the majority of patients/families opted for a Do Not Attempt CPR.ConclusionOur results have shown that there is a risk of substantial functional decline associated with successful CPR in those patients over the age of 80 years. The majority of patients and relatives contacted after successful resuscitation expressed a negative view of the experience. Our study highlights the importance of having early informed discussions with patients and families about CPR in order to avoid detrimental outcomes and ensure patient wishes are correctly represented.

Perkins G.D., Fritz Z.

Kidd A.C., Honney K., Bowker L.K., Clark A.B., Myint P.K., Holland R.

Background: It is unclear whether doctors base their resuscitation decisions solely on their perceived outcome. Through the use of theoretical scenarios, we aimed to examine the ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decision-making. Methods: A questionnaire survey was sent to consultants and specialty trainees across two Norfolk (UK) hospitals during December 2013. The survey included demographic questions and six clinical scenarios with varying prognosis. Participants were asked if they would resuscitate the patient or not. Identical scenarios were then shown in a different order and doctors were asked to quantify patients’ estimated chance of survival. Results: A total of 137 individuals (mean age 41 years (SD 7.9%)) responded. The response rate was 69%. Approximately 60% were consultants. We found considerable variation in clinician estimates of median chance of survival. In three out of six of our scenarios, the survival estimated varied from <1% to 95%. There was a statistically significant difference identified in the estimated median survival between those clinicians who would or would not resuscitate in four of the six scenarios presented. Conclusion: This study has highlighted the wide variation between clinicians in their estimates of likely survival and little concordance between clinicians over their resuscitation decisions. The diversity in clinician decision-making should be explored further.

Ouellette L., Puro A., Weatherhead J., Shaheen M., Chassee T., Whalen D., Jones J.

Hwang H., Yang S.J., Jeong S.Y.

This descriptive cross-sectional survey aimed to investigate the preferences of older inpatients and their family caregivers for life-sustaining treatments (LSTs) and their influential factors. Inpatients aged 60 and older and their family caregivers in three acute hospitals in Seoul, South Korea, were invited to participate in the study. A total of 180 surveys were returned from 90 pairs of patients and family caregivers with a response rate of 95%. Older inpatients expressed a significantly high desire for "not wanting to have cardiopulmonary resuscitation" (χ2 = 10.07, p = 0.007) and "mechanical ventilator" (χ2 = 10.35, p = 0.006) compared to their caregivers. Given that experiences of conversations about LSTs was a common factor in both groups and may prevent futile LSTs, it is important for nurses to initiate and support patients and family caregivers, helping them engage in formal and informal conversations about future healthcare preferences.

Cartledge S., Straney L.D., Bray J.E., Mountjoy R., Finn J.

Background Residential aged care facilities are common locations for out-of-hospital cardiac arrests to occur, yet survival to hospital discharge is poor. Aim This study aims to examine preferences and perceived outcomes of cardiopulmonary resuscitation among Australians receiving aged care. Methods A brief survey was provided to 187 residential aged care facilities and 34 home care providers throughout Australia for completion by aged care residents. Respondents were asked to answer three questions about understanding and desire for cardiopulmonary resuscitation on a five-point scale (from strongly agreed to strongly disagreed). Findings A total of 1985 residents in 163 residential aged care facilities across Australia, and 277 older Australians receiving care in the home from 24 providers responded. The majority of respondents were female (67.4%), and respondents in residential aged care facilities were significantly older (82.6%>75years) than those receiving care in the home (70.4%>75years) (p Conclusion These findings highlight the need for older people to be better informed about cardiopulmonary resuscitation, including a clear understanding of what is involved in cardiopulmonary resuscitation and a realistic perception of outcomes.

Ramages M., Cheung G.

There is a dearth of qualitative research on resuscitation preferences of older New Zealanders. The aim of this study was to investigate the resuscitation preferences of older New Zealanders in a retirement village or residential care setting, as well as the reasons for these preferences.This study had 37 participants from two retirement villages in Auckland, New Zealand. Participants were interviewed about a hypothetical case vignette about cardiopulmonary resuscitation, and then they completed a semi-structured interview. Interviews were subsequently transcribed and analyzed by two independent researchers using thematic qualitative methodology.The majority of the participants (n = 25, 67.6%) decided against resuscitation, 10 (27.0%) wanted resuscitation, and 2 (5.4%) were ambivalent about their resuscitation preferences. Three main themes emerged during the data analysis regarding participants' reasons for deciding against resuscitation: (i) the wish for a natural death; (ii) advanced age; and (iii) a realistic awareness about the consequences of resuscitation. Responses related to the third these had three subthemes: (i) reduced quality of life; (ii) loss of personal integrity and sense of existence; and (iii) concern that resuscitation could result in unnecessary costs or a burden on others. Among participants who preferred resuscitation, two main themes emerged regarding their reasons for wanting resuscitation: (i) the wish to prolong a good quality of life; and (ii) unrealistic expectations of resuscitation.Older people in this study were able to make reasoned decisions about resuscitation based on balancing their subjective estimations of quality of life and the presumed consequences of resuscitation. It is important therefore to educate older adults about the potential outcomes of resuscitation and explore (and document) their reasoning when discussing resuscitation preferences so their wishes can be respected.

Levinson M., Mills A., Barrett J., Sritharan G., Gellie A.

Objective The aim of the present study was to understand the reasons for the delivery of non-beneficial cardiopulmonary resuscitation (CPR) attempts in a tertiary private hospital over 12 months. We determined doctors’ expectations of survival after CPR for their patient, whether they had considered a not-for-resuscitation (NFR) order and the barriers to completion of NFR orders. Methods Anonymous questionnaires were sent to the doctors primarily responsible for a given patient’s care in the hospital within 2 weeks of the unsuccessful CPR attempt. The data were analysed quantitatively where appropriate and qualitatively for themes for open-text responses Results Most doctors surveyed in the present study understood the poor outcome after CPR in the older person. Most doctors had an expectation that their own patient had a poor prognosis and a poor likely predicted outcome after CPR. This implied that the patient’s death was neither unexpected nor likely to be reversible. Some doctors considered NFR orders, but multiple barriers to completion were cited, including the family’s wishes, being time poor and diffusion or deferral of responsibility. Conclusions It is likely that futile CPR is provided contrary to policy and legal documents relating to end-of-life care, with the potential for harms relating to both patient and family, and members of resuscitation teams. The failure appears to relate to process rather than recognition of poor patient outcome. What is known about the topic? Mandatory CPR has been established in Australian hospitals on the premise that it will save lives. The outcome from in-hospital cardiac arrest has not improved despite significant training and resources. The outcome for those acutely hospitalised patients aged over 80 years has been repeatedly demonstrated to be poor with significant morbidity in the survivors. There is emerging literature on the extent of the delivery of non-beneficial treatments at the end of life, including futile CPR, the recognition of harms incurred by patients, families and members of the resuscitation teams and on the opportunity cost of the inappropriate use of resources. What does this paper add? This is the first study, to our knowledge, that has demonstrated that doctors understood the outcomes for CPR, particularly in those aged 80 years and older, and that failure to recognise poor outcome and prognosis in their own patients is not a barrier to writing NFR orders. What are the implications for practitioners? Recognition of the poor outcomes from CPR for the elderly patient for whom the doctor has a duty of care should result in a discussion with the patients, allowing an exploration of values and expectations of treatment. This would promote shared decision making, which includes the use of CPR. Facilitation of these discussions should be the focus of health service review.

Abdul-Razzak A., Heyland D.K., Simon J., Ghosh S., Day A.G., You J.J.

ObjectivesTo quantify agreement between patients and their family members on their own values and preferences for use or non-use of life-sustaining treatments for the patient.MethodsHospitalised patients aged 55 years or older with advanced pulmonary, cardiac, liver disease or metastatic cancer or aged 80 years or older from medical wards at 16 Canadian hospitals and their family members completed a questionnaire including eight items about values related to life-sustaining treatment and a question about preferences for life-sustaining treatments.ResultsWe recruited a total of 313 patient-family member dyads. Crude agreement between patients and family members about values related to life-sustaining treatment was 42% across all eight items but varied widely: 20% when asking how important it was for the patient to respect the wishes of family members regarding their care; 72% when asking how important it was for the patient to be kept comfortable and suffer as little as possible. Crude agreement on preferences for life-sustaining treatment was 91% (kappa 0.60; 95%CI 0.45 to 0.75) when looking at preferences for cardiopulmonary resuscitation (CPR) versus no CPR but fell to 56% when including all five response options with varying degrees of resuscitative, medical or comfort options (kappa 0.39; 95%CI 0.31 to 0.47).ConclusionsThere is appreciable disagreement between seriously ill hospitalised patients and family members in their values and preferences for life-sustaining treatment. Strategies are needed to improve the quality of advance care planning, so that surrogates are better able to honour patient’s wishes at the end of life.