Disclosures: Bernacki reports receiving grants from the National Heart, Lung, and Blood Institute. Please see the study for all other authors’ relevant financial disclosures.
September 09, 2020
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CPR preferences may differ from other end-of-life care choices for patients on dialysis

Disclosures: Bernacki reports receiving grants from the National Heart, Lung, and Blood Institute. Please see the study for all other authors’ relevant financial disclosures.
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Study findings indicated that while most patients on dialysis reported that they wanted CPR performed if their “heart were to stop beating,” these preferences were not always associated with other aspects of end-of-life care.

Based on these results, Gwen M. Bernacki, MD, MHSA, of the department of medicine at the University of Washington in Seattle, and colleagues suggested it is necessary to improve patients’ understanding of the potential outcomes after CPR, as well as to integrate code status discussions with “broader conversations about their values, goals and preferences for end-of-life care.”

CPR
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The researchers noted patients who receive dialysis have a significantly greater likelihood of dying prematurely from cardiac arrest compared to the general population, with less than 25% of patients who experience a cardiac arrest during a dialysis treatment surviving to hospital discharge. In addition, they contended that prior studies show less favorable outcomes following cardiac arrest for this patient population, who are also more likely to be discharged to a skilled nursing facility if they survive.

“Despite their generally poor outcomes after resuscitation, available data suggest that patients receiving dialysis are much more likely to receive cardiopulmonary resuscitation (CPR) than members of the general population,” Bernacki and colleagues wrote. “These patients are also more likely to receive intensive patterns of end-of-life care focused on life prolongation compared with some other seriously ill populations.”

As, the researchers added, previous data show patients with advanced kidney disease frequently indicate they value comfort and relief from pain over survival, they sought to gain a better understanding of how patient preferences on CPR relate to other end-of-life care choices.

To do this, they surveyed 876 patients receiving dialysis at facilities in Seattle and Nashville (mean age, 62.6 years; 60.3% were white). All patients 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?” Patients were then categorized into two groups: definitely or probably wanting CPR (“the CPR group,” which consisted of 84.2% of patients surveyed) or no CPR (do not resuscitate [DNR] group).

According to the researchers, based on self-reported characteristics, patients who were younger, Black, placed an importance on spiritual and/or religious beliefs and who were on dialysis for longer periods of time were more likely to prefer CPR.

Survey results showed 75.2% of those in the CPR group wanted mechanical ventilation compared with 9.4% of those in the DNR group and 33.7% of patients in the CPR group had documented treatment preferences vs. 60.9% in the DNR group.

Regarding values about future care, the researchers found substantially more patients in the CPR group valued life prolongation compared with those in the DNR group (23.2% vs. 3.6%), while more patients in the DNR group valued comfort (79% vs. 43.4%). Patients in the CPR group were also more likely to be “unsure” about their wishes for future care than those in the DNR group (33.5% vs. 17.4%) and less likely to have considered or discussed stopping dialysis (28% vs. 44.9% and 24.5% vs. 42%, respectively).

“CPR preference was associated with some, but not all, of the other domains of end-of-life care that were examined,” Bernacki and colleagues wrote of the findings. “Furthermore, study participants’ CPR preferences were not always aligned with how they responded to questions about these other aspects of end-of-life care. 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.”

In a related editorial, Davene R. Wright, PhD, of Harvard Medical School and Harvard Pilgrim Health Care Institute, wrote that the study is a “good” first attempt in examining patient views on CPR, but that the study is limited by design, making it difficult to accurately interpret what these results suggest.

“Preferences measure, in part, a patient’s willingness to accept the risks associated with treatments,” Wright elaborated. “Wants, on the other hand, can represent desires without constraints and under conditions of certainty. In the case of one’s health state after CPR, there is likely a great deal of uncertainty.”

It is important to evaluate the “trade-offs patients are willing to make in exchange for the outcomes they are seeking,” according to Wright.

“It is not surprising that such a high percentage of patients reported ‘preferences’ for CPR,” she argued. “The way the question was framed, 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.”