views on resuscitation research study jeena ackroyd lynne russon rob newell
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Views on ResuscitationResearch study
Jeena Ackroyd
Lynne Russon
Rob Newell
Background• Joint Statement ,BMA,RCN,RC(2001)
– Guidelines on decision-making– Has contradictions
• States that resuscitation should be discussed with all competent patients who are terminally ill
• But also states that if resuscitation not appropriate doctors do not need to discuss it but ‘ should whenever possible, respect patient’s wishes to receive treatment which carries only a very small chance of success’
Background• APM (2002)
• ‘no ethical obligation to discuss CPR with patients for whom such treatment… is futile’
• Do not discuss ALL treatments with patients
Success rates• Poor outcome with
– Metastatic cancer– Cardiogenic shock– Creatinine > 150umol/l– Pneumonia– Recent stroke– pO2 < 6kpa– Sepsis
• Good outcome with
• Witnessed arrest• CPR < 5 mins• Ventricular arrhythmias
O’Keefe 1991
Background• Previous studies on patients and doctors
views on resuscitation – elderly (Mead and Turnbull,1995)– general medical patients (Hill,1994)
• Useful to know what the views of oncology patients are
• Success rates are lower
Aims1. Investigate oncology patients and their
next of kin’s views on whether resuscitation should be discussed with them
2. Views compare with oncologist
Method• Questionnaire based study
• 21 bedded oncology ward
• Consecutive admissions – patient info leaflet on CPR – info sheet about study
• If agreed • Questionnaire • Permission for nok to enter
Method• Oncologist filled in
data sheet – Demographic info
– prognostic score– WHO performance
status
– Whether patient should be resuscitated
• Hypotension• Pneumonia• Sepsis• Recent stroke• Creatinine greater
than 150umols• Over 70 years old
O’Keefe 1991
Ethics Committee• Anxious re issues raised
• Echoed by some ward staff
• Support measures put in place ‘help-line’– Palliative care– oncology
Results
Results
30 male and 30 female
11 localised cancer 49 metastatic disease
60 patients31-83yrs 28 nok
Frequency percent
Lung 17 28.3
Breast 13 21.7
Upper GIT 12 20
Lower GIT 6 10
Gynae 5 8.3
Unknown 5 8.3
G-U 1 1.7
Other 1 1.7
TOTAL 60 100
Disease Characteristics
NDN
(%)
NPN
(%)
DK
(%)
YP
(%)
YD
(%)
Patient wants CPR
3(5) 9(15) 5(8.3) 8(13.3) 35(58.3)
CPR discussed if not successful
3(5) 7(11.7) 2(3.3) 11(18.3) 37(61.7)
CPR discussed if approp
0 3(5) 0 11(18.3) 37(61.7)
CPR discussed if uncertain
1(1.7) 5(8.3) 4(6.7) 7(11.7) 43(71.7)
Should Dr always discuss CPR
1(1.7) 5(8.3) 3(5) 12(20.3) 38(64.4)
Patients views
NDN
(%)
NPN
(%)
DK
(%)
YP
(%)
YD
(%)
Nok wants Patient for CPR
1(3.1) 2(6.3) 4(12.5) 5(15.6) 20(62.5)
Should Dr always discuss CPR with patient
1(3.1) 2(6.3) 0 2(6.3) 27 (84)
Should nok be involved in decision
2(6.3) 1(3.1) 0 7(21.9) 22(68.8)
Should drs make final decision
5(15.6) 6(18.8) 5(15.6) 7(21.9) 9(28.1)
Next of kins views
Consultants responsesYes No DN
Is CPR appropriate for patient(%)
16(26.7) 34(56.7) 10(16.7)
Should CPR be discussed with patient(%)
13(21.7) 47(78.3)
Should CPR be discussed with nok(%)
Yes 2(3.3) 58(96.7)
Results• Moderate-strong correlation between
patients’ and next of kin’s desire for patient to be resuscitated Tau-b=0.499 and p=0.002
• Positive correlation between Dr’s views on suitability for resuscitation and patients prognostic score and WHO ps
Results• 34 patients(56.7%) deemed not for
resuscitation by consultant
1. 5 probably and 17 definitely wanted CPR
2. only 1of 34 had resuscitation discussed with them.
Results• Age not related to desire for resuscitation
or doctor’s ratings for appropriateness for resuscitation
• Consultants more likely to judge resuscitation appropriate for male patients than female patients (U=292.0. p =0.009) – No gender difference in prognostic
score,WHO or age
Results• Consultants more likely to deem curative group
for resuscitation(U=44.5, p=0.001)
• no difference in desire for resuscitation between palliative and curative groups, – curative numbers small (n=9).
• even in advanced stages of illness patients still want to be resuscitated
Discussion
Discussion• Most patients definitely want CPR (58%)
– Despite being given success rates– Echoed by nok ‘patients have the right to make decision with regard to
their life’
‘I would like to live; that would be my heart beating’
• Age was not related to whether a patient wanted resuscitation
Next of kin involvement• Oncology patients also want the doctor to discuss
resuscitation with them and their next of kin support this.
• Most patients (70%) want nok involved in discussion
• strong correlation between patient and next of kin wanting the doctor to always discuss resuscitation with patient.
• only (31%) patients and (28%) relatives wanting the doctor to make the final decision- shared decision-making important.
• No association with age and consultants view on appropriateness for resuscitation
• Consultants more likely to think females less appropriate for resuscitation,– despite no gender difference in
prognostic score and WHO status,or age. – not explained by stage or type of disease,
discrepancy between doctor and patients views.
• majority of patients do not have resuscitation discussed with them- doctor making final decision.
• Drs felt only 13 of 60 patients (21.7%) needed to have resuscitation discussed with them.
• Consultants– significant correlation
with consultant views and prognostic score and WHO performance
- doctors more likely to base decisions on clinical outcome factors.
• Patients – Survival rates had no
impact– ?Patients likely to
base decisions on• quality of life issues,• goals, • desire for a chance
of life• Hope
Conclusion• Despite survival rates oncology patients still
want resuscitation – need other methods of understanding outcomes
• Majority of patients want to be involved with decision - with nok
• Direct discussion important as no predictors of seeing which patients were more or less likely to want resuscitation– reasons for not being resuscitated should be justified
Conclusion• Doctors remain reluctant to discuss
resuscitation– No duty to provide treatment that is not
beneficial• Majority of patients want to be involved
• Doctors should feel less intimidated by discussion
BMJ 2001;323:58 ( 7 July )