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End-of-life care discussions can lead to more thoughtful use of CPR

In a recently released position paper, leading internists are urging physicians to have honest end-of-life discussions with patients — including patient’s wishes and prognosis — to determine if CPR is in their best interest.

“Too often CPR occurs regardless of prognosis, without knowing whether the patient desires CPR, and knowing that we may do harm. Hospitals must be environments where patients routinely learn about their options and prognosis and express their preferences,” Frank H. Bosch, MD, PhD, department of internal medicine, Rijnstate Hospital, the Netherlands, and ACP President David A. Fleming, MD, MA, wrote.

David A. Fleming

Typically, CPR consent is implied, unless a patient has clearly stated their wish to be designated do not resuscitate (DNR). The authors point out that the flaw with this standardization is that CPR outcomes are commonly bleak, with only 20% of patients surviving to hospital discharge. Patients who do survive are often at risk for injury and substantial functional impairment.

Fleming and Bosch note that use of technical treatment approaches, professional judgement, fear of legal action and optimism regarding prognosis are all factors that may lead to the use of CPR. Additionally, the notion among both physicians and patients that a DNR status could lead to loss of hope and/or a deficiency in care quality and attention, may also be cause for the initiation of CPR, despite these ideas being unfounded.

The paper stresses the importance of physicians being honest with their patients regarding prognosis and risk factors for CPR to determine if a patient wants to undergo this potentially life-sustaining and aggressive treatment, regardless of their chance of survival. Furthermore, thoroughly documenting patient’s wishes, and updating their medical records at each hospitalization to ensure the records reflect the most current clinical circumstances is vital to ensuring the proper care plan is followed.

“In an era when we are striving for better value in health care, we must be frank with ourselves and our patients, that CPR often offers limited value. Hospitals must be environments where deteriorating vital signs are evaluated quickly, patients will not have acute events unnoticed, and CPR Is performed only when clinically indicated, on the basis of patient preferences and the realistic chances of benefit. Together, patients and physicians can enhance the appropriate use of CPR by recognizing the limits of what it offers some patients and gaining a better understand of our patient preferences,” Fleming and Bosch wrote. – by Casey Hower

Disclosure: The researchers report no relevant financial disclosures.