Views on Resuscitation Research 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

Aims 1.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

30 male and 30 female 11 localised cancer49 metastatic disease 60 patients 31-83yrs 28 nok

Frequencypercent Lung Breast Upper GIT1220 Lower GIT610 Gynae58.3 Unknown58.3 G-U11.7 Other11.7 TOTAL60100 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 03(5)011(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 27 (84) Should nok be involved in decision 2(6.3)1(3.1)07(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 responses YesNoDN 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= 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

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 )