Patients/Surrogates Vastly Overrate Likelihood of Survival after Cardiac Arrest
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh. Dr. Hoffman reports no financial relationship to this field of study.
This article originally appeared in the August 2011 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and was peer reviewed by William Thompson, MD. Dr. Pierson is Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: Most (83%) patients/surrogates stated they preferred full code status but only 4% could identify the components of CPR; 16% stated preferences that differed with the medical record.
Source: Gehlbach TG, et al. Code status orders and goals of care in the medical ICU. Chest 2011;139:802-809.
Participants in this study were 100 patients/surrogates and their physicians in a 26-bed medical ICU located in an academic medical center. Patients/surrogates were questioned regarding their knowledge of cardiopulmonary resuscitation (CPR), code status preferences, and goals of care. Physicians were queried about goals of care and treatment plans. Interviews were conducted by a critical care fellow who selected participants from a randomized list of bed numbers generated each study day. The final sample included 20 patients and 80 surrogates. Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Most (83%) stated they preferred full code status, but only 4% could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). Almost all charts (98%) documented code status. For 16%, discrepancies existed between patient/surrogate's stated preference during the interview and orders in the medical record. Patients/surrogates estimated survival to hospital discharge following in-hospital cardiac arrest with CPR at 71.8% (range, 10% to 100%) and the higher the prediction of survival, the greater the frequency of preference for full code status (P = 0.012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed from their physicians about the most important goal of care.
When making decisions about code status orders, it is important to communicate effectively so that patients and families receive care that respects their preferences. Discussions about code status can be challenging and misunderstandings can lead to unwanted interventions. Findings of this study suggest that patients/surrogates rate their understanding as "high" but in reality do not fully understand what is involved in procedures commonly used in critical illness (e.g., CPR), and the likely outcome. Patient/surrogate estimates of survival after CPR in the ICU were extremely high (71.8%) compared to an evidence-based likelihood of 16% for ICU patients and 18% for patients on general wards. When queried about what was involved in CPR, most (65%) participants believed they had good knowledge of what CPR involved and most (71%) were able to identify use of chest compressions. However, far fewer identified cardiac defibrillation (32%) or the potential for intubation (7%). Study findings did not identify whether the problem related to clinicians not clearly describing possible outcomes or patients/surrogates indicating they understood when, in fact, they did not.
Discussions about decision making at the end-of-life are inherently challenging. Of note, the majority (80%) of participants in this survey felt it was helpful to talk about chances of survival after CPR and helpful (70%) to specifically discuss the goals of care. The take-home message from this study is that patients/surrogates may have an incomplete or incorrect understanding that is not recognized without probing questions. In this age of television dramas in which the "patient" almost always fully recovers, it is perhaps not unexpected that patients/surrogates have an incomplete understanding, as evidenced in this study.