Hospitalized patients who watched a video about code status choices were less likely to choose full code, and more likely to choose do not resuscitate (DNR) or do not intubate, found a study of 119 patients hospitalized on the general medicine service at Minneapolis Veterans Affairs Health Care System in Minnesota.1

“We were not surprised that fewer patients chose CPR and intubation after being presented with the facts about the likelihood of survival after these interventions,” says Aimee Merino, MD, the study’s lead author. Merino is a fellow in the department of hematology, oncology, and transplant at University of Minnesota in Minneapolis.

What was surprising was the reaction of other professionals to the idea of using a video to educate patients about resuscitation, she says. The institutional review board voiced concerns that viewing the video could be psychologically stressful for patients.

“This seems to suggest, at least amongst some medical professionals, that patients are not seen to have either the right to know, or the ability to understand, the risks and benefits of resuscitation,” says Merino.

Many participants who watched the video expressed gratitude for the information. “A few requested that we allow their family members to view it,” says Merino.

Many patients hear information on CPR and intubation from television shows. “This often distorts the risks and benefits of undergoing these interventions, as well as outcomes for survival and functionality if successfully resuscitated,” says Merino.

Most physicians are not trained to hold these discussions. “Put together, these factors bring into question the effectiveness of the current approach to informed consent for resuscitation efforts,” says Merino.

Anecdotal accounts and research on resource utilization suggest that implementation of futile care is widespread at the end of life.2,3

Standardization of certain aspects of the code status conversation could prevent this, suggests Merino. “Ultimately, improved decision-making should better align patient choices with their true intention around code status,” she says.

Tools to standardize conversations regarding informed consent for end-of-life care must never be used as the sole source of information for decision-making, cautions Merino. “Healthcare providers must still have a deep understanding of how to guide a patient through the process of making decisions about code status, provide recommendations, and support the decision in times of uncertainty,” she says.

There is no “one size fits all” approach to complex medical decision-making. “Cultural diversity and demographic differences often necessitate an individualized approach to these discussions,” says Ryan Greiner, MD, another of the study’s authors and the producer of the video.

Decision aids raise an ethical question as to whether it’s appropriate for providers to use the tool to support a specific recommendation, or if the tool should be neutral and objective. “We need to answer the question of whether decision aids, like videos, should or shouldn’t be persuasive in their intent,” says Greiner, an internist at North Memorial Health in Robbinsdale, MN.

Music, visuals, and the commentator’s tone all have the potential to subconsciously influence the patient’s decision. “As a professional body, we will have to decide if it is okay to manipulate these variables to get a desired outcome,” says Greiner.

REFERENCES

1. Merino AM, Greiner R, Hartwig K. A randomized controlled trial of a CPR decision support video for patients admitted to the general medicine service. J Hosp Med 2017; 12(9):700-704.

2. Hoover DR, Crystal S, Kumar R, et al. Medical expenditures during the last year of life: findings from the 1992–1996 Medicare Current Beneficiary Survey. Health Serv Res 2002; 37(6):1625–1642.

3. Hogan C, Lunney J, Gabel J, et al. Medicare beneficiaries’ costs of care in the last year of life. Health Aff (Millwood) 2001; 20(4):188–195.

SOURCES

• Ryan Greiner, MD, North Memorial Health, Robbinsdale, MN. Phone: (708) 935-9056. Email: ryan.greiner@northmemorial.com.

• Aimee Merino, MD, PhD, Department of Hematology, Oncology, and Transplant, University of Minnesota, Minneapolis. Phone (612) 624-0123. Email: merin008@umn.edu.