Study suggests patients don't understand CPR
Study suggests patients don't understand CPR
University of Iowa implements new policy
A study completed by researchers at the University of Iowa Carver College of Medicine suggests that many patients who are hospitalized do not fully understand all the steps involved in cardiopulmonary resuscitation — or their chances of surviving an in-hospital cardiac arrest.1
Lauris C. Kaldjian, MD, PhD, associate professor in the Department of Internal Medicine, as well as director of the program in bioethics and humanities, explained the impetus behind the study.
"Code status discussions seem to come out of nowhere; they tend to be dropped into a doctor-patient or doctor-family discussion without a sense of context or framework, and that tends to be the way that most of us, I think, have been professionalized in our careers," Kaldjian says.
Often, he says, the conversation on code status is introduced at the end of a patient history and physical examination process as someone is being admitted to the hospital.
"It usually is scarcely introduced, and it typically is not preceded by a sense of context to help someone understand where the question is coming from," he says.
Although that is sometimes unavoidable, depending on the patient's condition upon admission, in even urgent circumstances, he suggests there would still be another 5-7 minutes a physician could take with the patient to "set the stage and discuss the goals of care and say, 'Mr. Jones, I want to talk to you about what the overall purpose of your hospitalization is. As I understand it, based on what you've told me so far, your goals would be as follows. Have I heard you correctly?'"
The conversation could then proceed from goals of care as indicated by the patient to the physician introducing the subject of code status.
"It's that kind of phraseology where you can first set the stage and then talk about a particular intervention, " Kaldjian explains. "And then the physician can even help the patient walk through the connections that they need to make. And to say, 'Well, if my goal is such and such, does resuscitation in my circumstances make sense or not?'"
Kaldjian says to his knowledge, no other studies have addressed in-hospital patients looking at the "CPR question plus the goals of care."
The study's findings
In introducing the study, the authors write that code status "communication can be difficult, and studies suggest that doctors often misunderstand patients' code status preferences, even in the setting of serious illness."
"There is a need to improve the quality of code status discussions so that patient preferences can be ascertained and implemented," the authors also write.
One possible barrier to the discussion of code status may be that often, physicians are unaware of the patients' goals of care. Without the goals of care as a guide, Kaldjian says, it is difficult to make the correct decisions regarding potential interventions.
In the study, 135 adults were interviewed within 48 hours of admission. Of those, 41, or 30.4%, had discussed CPR with their doctor; 116, or 85.9%, preferred full code status and 11, or 8.1%, expressed code status preferences different from the code status documented in their medical record.1
The study found that older patients were more likely to have discussed code status with their doctors but were less likely to want full code status.
There was a discrepancy between patients' perceived knowledge of what CPR entails vs. their actual knowledge. That is, 98 patients, or 72.6% expressed a perceived knowledge, but only 40, or 29.6%, accurately understood the process of CPR.
"I think people tend to associate CPR with what they see on television, and often, that can be seen as something that is less technically involved and more like the kind of life support skills that any citizen can be certified in if they take an approved course to learn how to do basic CPR," Kaldjian says.
He explains the three parts of CPR as follows: the use of a defibrillator, i.e., applying electricity to the heart externally; chest compressions; and lastly, intubation, or putting a tube in the patient's windpipe and hooking them to a breathing machine.
Of the patients interviewed, 116, or 85.9%, preferred all three components of CPR.
Patients also "greatly overestimated the probability of surviving a cardiac arrest in a hospital. When patients were informed about the true statistics involving survival of CPR, "some patients were less interested in receiving CPR."
In fact, the chance of surviving CPR long enough to leave the hospital is only about 15%.1
Two of the barriers to appropriate code status discussions involve knowledge and communication. Regarding the communication barrier, the study authors in the discussion write that "the implications of failures in this domain are reflected by the observation that for 8.1% of patients in our study, there was a discrepancy between their code status preferences and their code status as documented in their medical record."
The study found that "goals of care represent an approach to code status discussions that may improve communication." It also found that, since patients selected an average of 4.9 different goals, patients may have multiple goals at the same time, concluding that "the heterogeneity of patients' single most important goals of care emphasizes the importance of soliciting patients' goals rather than presuming to understand them on the basis of general clinical impressions."
Of the patients, 70% said they found it helpful to discuss goals of care.
University of Iowa's new policy
In May, according to Kaldjian, who also chairs the hospital's ethics committee, the University of Iowa implemented a new policy requiring physicians to discuss goals of care with all hospitalized patients, regardless of their condition or prognosis.
"[The policy] places code status discussions within a framework of goals of care," Kaldjian explains. "And the way we say it is to say, ideally, every patient in our hospital should have a goals of care discussion with their physician."
He admits that some physicians might not feel this is necessary with all patients; however, he says the health care system believes that "as a matter of policy," these discussions should take place.
"By contrast, it's not that every patient in the hospital needs to have a code status discussion," he says. "Some people might disagree with that, but I, as a clinician, think that sometimes when you have people who are otherwise relatively healthy and there's no reason to think that they might not want to be resuscitated in the event of a cardiac arrest, sometimes it can actually be disturbing to the doctor/patient relationship to raise a question that seems to be irrelevant."
Reference
- LC Kaldjian, et al. Code status discussions and goals of care among hospitalised adults. J. Med. Ethics 2009;35;338-342.
Source
- Lauris C. Kaldjian, MD, PhD, Associate Professor, Department of Internal Medicine, and Director, Program in Bioethics and Humanities, University of Iowa Carver College of Medicine; Iowa City, IA. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.