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Communication interventions may improve do-not-resuscitate decisions, discussions

Communication interventions, including videos, are strongly associated with patient decisions regarding do-not-resuscitate code status and improve patient knowledge about resuscitation measures and outcomes, according study findings published in JAMA Network Open.

By taking a more proactive approach, clinicians may improve do-not-resuscitate (DNR) code status discussions and enable patients to more actively participate in the decision-making process, according to the researchers.

“To inform patients about treatment options in case of a cardiac arrest and their involvement in the decision-making process regarding their code status is considered a cornerstone of patient-centered care,” Christoph Becker, MD, of the department of emergency medicine and medical communication for the department of psychosomatic medicine at University Hospital Basel, Switzerland, and colleagues wrote. “Physicians are encouraged to conduct such code status discussions to respect patient autonomy as an ethical principle.”

“However, physicians often omit code status discussions or do not describe resuscitation measures, such as chest compressions or mechanical ventilation,” they continued.

Becker and colleagues conducted a systematic review and meta-analysis of randomized control trials to determine associations between communication interventions and patient decisions and knowledge of CPR. Trials that focused on patient preference for resuscitation, DNR orders or patient knowledge after receiving communications interventions or usual care were included in the study.

Fifteen eligible randomized control trials involving 2,405 patients were eligible for the study after exclusions. Among those, 11 studies (n = 1,463 patients) were used to evaluate patient preferences for CPR, and five studies (n = 652 patients) assessed patient knowledge about life-sustaining treatment.

Researchers found that communication interventions lowered patient preference for CPR from 53.6% to 38.6% (RR = 0.7; 95% CI, 0.63-0.78).

The use of resuscitation videos as decision aids was tied to a stronger decrease in preference for life-sustaining treatment (RR = 0.56; 95% CI, 0.48-0.64) compared with other interventions (RR = 1.03; 95% CI, 0.87-1.22).

Communication interventions were significantly associated with increased patient knowledge about resuscitation procedures (standardized mean difference = 0.55; 95% CI, 0.39-0.71).

Researchers noted that only three studies included in their analysis involved a communication intervention other than videos, demonstrating a need for additional trials of different communication interventions for code discussions.

“Linking discussions about resuscitation with decisions about other aspects of emergency care and treatment helps to provide greater clarity about the goals of care, can aid communication among clinicians, and may reduce the harms identified from decisions that focus only on with holding resuscitation,” Gavin D. Perkins, MD, FRCP, FFICM, of the Warwick Clinical Trials Unit at Warwick Medical School, Coventry, and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom, and Zoe Fritz, PhD, FRCP, of the Healthcare Improvement Studies Institute and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom, wrote in an editorial accompanying the study.

“In supporting the call from Becker et al for large randomized clinical trials to investigate the best approaches to facilitate DNR decisions, perhaps future research should focus on the optimal approach to overall treatment plans, rather than DNR in isolation,” they continued. – by Erin Michael

Disclosures: Becker report no relevant financial disclosures. Fritz and Perkins reported grants from the National Institute for Health Research Health Service Delivery Research Program. Fritz reported a grant from Wellcome Trust, serves on the executive committee of Resuscitation Council (U.K.) and chairs the subcommittee of the Recommended Summary Plan for Emergency Care and Treatment. Perkins reported receiving support from the Intensive Care Foundation and serves on the Resuscitation Council Executive Committee and ReSPECT working group. Please see the full study for all other authors’ relevant disclosures.