Study finds their desire for resuscitation does not align with their advance directives

According to a cross-sectional survey of patients receiving dialysis at 31 nonprofit dialysis centers in Seattle and Nashville, 84% reported they would probably or definitely want cardiopulmonary resuscitation (CPR) if their hearts stopped beating. However, that desire does not necessarily align with their end-of-life preferences and goals.

“More work is needed to integrate discussions about code status with bigger picture conversations about patients’ values, goals, and preferences for end-of-life care,” concluded Gwen M. Bernacki, MD, MHSA, Department of Medicine, University of Washington, Seattle, and colleagues. The study was published in JAMA Network Open.

Bernacki and colleagues pointed out that patients with end-stage kidney disease who receive maintenance dialysis not only have high mortality rates but are much more likely than the general population to die prematurely of cardiac arrest. For example, studies have shown that people undergoing dialysis are 20 times more likely to experience out-of-hospital sudden cardiac death compared to the general population, while just a quarter of patients who experience cardiac arrest when on dialysis treatment survive to hospital discharge.

Despite the likelihood of a poor outcome after resuscitation, Bernacki and colleagues added, the data indicate that patients on dialysis are more likely to receive CPR than the general population. Therefore, in this study, the authors surveyed the CPR preferences of patients undergoing dialysis.

Over 1,000 eligible patients completed the survey, 876 of whom were included in the final study cohort. Respondents were asked to respond to the question: “If you had to decide right now, would you want CPR if your heart were to stop beating?” Those patients who indicated they would probably or definitely want CPR were classified as preferring CPR.

The authors then examined the association between the preference for CPR and 9 study outcomes, which included the preference for mechanical ventilation, engagement in advance care planning, values around life prolongation, thoughts or prior discussions about whether or not to stop dialysis, thoughts or prior discussions about receiving hospice care, desired place of death, expectations regarding prognosis, presence or absence of symptoms, and palliative care needs.

Of the 876 respondents 65.3% reported they definitely wanted to be resuscitated, while 18.9% said they probably would (for a combined 84.2% CPR group), while the remainder did not want resuscitation (DNR group). Bernacki and colleagues found that:

  • 75.2% of the CPR group wanted mechanical ventilation compared to 9.4% of the DNR group.
  • 33.7% of the CPR group had documented their treatment preferences versus 60.9% in the DNR group.
  • 23.2% in the CPR group valued life prolongation compared 3.6% in the DNR group.
  • 43.4% in the CPR group value comfort versus 79.0% in the DNR group.
  • 33.5% in the CPR group were unsure about their wishes for future care compared to 17.4% in the DNR group.
  • 28.0% in the CPR group compared to 44.9% in the DNR group had thought about stopping dialysis, while 24.5% in the CPR group had discussed stopping dialysis compared to 42.0% in the DNR group.

There were no statistically significant associations observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs.

“These findings argue for caution in extrapolating patients’ values, preferences, knowledge, and expectations pertaining to other aspects of end-of-life care from their resuscitation choice,” wrote Bernacki and colleagues. “Stronger efforts are needed to improve education around CPR and contextualize discussions about resuscitation preference within a broader conversation about end-of-life wishes for members of this population.”

In a commentary accompanying the study, Davene R. Wright, PhD, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, called it “a good first attempt at characterizing wants regarding CPR in this patient population.”

However, she added that it was not surprising that such a high number of patients indicated they wanted resuscitation. Considering the way the authors framed the question, she observed, “What was there to lose?”

“The risks and trade-offs were not specified in the survey question and therefore, I have some reservations about the validity of the primary survey measure utilized in this study for assessing CPR preferences and values,” wrote Wright. She added that attempts to devise decision support protocols for end-of-life care decisions should also ensure that the questions patients are asked “allow clinicians to accurately assess what patients truly want in the face of uncertainty and when facing a risk of negative outcomes.”

  1. According to a survey, most patients undergoing dialysis want CPR if their heart stops beating.

  2. That preference, however, doesn’t always align with other goals and preferences of end-of-life care.

Michael Bassett, Contributing Writer, BreakingMED™

Bernacki reported receiving grants from the National Heart, Lung, and Blood Institute.

Cat ID: 127

Topic ID: 81,127,254,730,127,192,925