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Biomedical subjects

J Teno

Publications and source records attributed to J Teno.

At least 19 recordsLinked to original sources
PubMed2001

Are aggressive treatment strategies less cost-effective for older patients? The case of ventilator support and aggressive care for patients with acute respiratory failure.

OBJECTIVES: A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estimated the incremental cost-effectiveness of providing mechanical ventilation and intensive care for patients of various ages who had acute respiratory failure. DESIGN: Retrospective analysis of data on acute respiratory failure from Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Acute hospital. PARTICIPANTS: 1,005 with acute respiratory failure; 963 received ventilator support and 42 had ventilator support withheld. MEASUREMENTS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (SUPPORT) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or = 10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUPPORT patients and estimated utilities (quality-of-life weights) using time-tradeoff questions. We used hospital fiscal data and Medicare data to estimate healthcare costs. We divided patients into three age groups (< 65, 65-74, and > or = 75 years); for each age group, we performed separate analyses for patients with a < or = 50% probability of surviving at least 2 months (high-risk group) and those with a > 50% probability of surviving at least 2 months (low-risk group). RESULTS: Of the 963 patients who received ventilator support, 44% were female; 48% survived 6 months; and the median (25th, 75th percentile) age was 63 (46, 75) years. For the 42 patients for whom ventilator support was withheld, the median survival was 3 days. For low-risk patients (> 50% estimated 2-month survival), the incremental cost (1998 dollars) per quality-adjusted life-year (QALY) saved by providing ventilator support and aggressive care increased across the three age groups ($32,000 for patients age < 65, $44,000 for those age 65-74, and $46,000 for those age > or = 75). For high-risk patients, the incremental cost-effectiveness was much less favorable and was least favorable for younger patients ($130,000 for patients age < 65, $100,000 for those age 65-74, and $96,000 for those age > or = 75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensitive to the costs of the index hospitalization. CONCLUSIONS: For patients with relatively good short-term prognoses, we found that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor short-term prognoses, ventilator support and aggressive care were much less cost-effective for adults of all ages.

Acute Disease↗
PubMed2000

Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

PURPOSE: Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. SUBJECTS AND METHODS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support. We estimated life expectancy based on long-term follow-up of SUPPORT patients. Utilities were estimated using time-tradeoff questions. Costs (in 1998 dollars) were based on hospital fiscal data and Medicare data. RESULTS: Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 dependence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator support was withheld, the median survival was 3 days. Among patients whose estimated probability of surviving at least 2 months from the time of ventilator support ("prognostic estimate") was 70% or more, the incremental cost per quality-adjusted life-year (QALY) saved by providing rather than withholding ventilator support and aggressive care was $29,000. For medium-risk patients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate < or =50%), it was $110,000 per QALY. When assumptions were varied from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76, 000 for medium-risk patients, and from $67,000 to $200,000 for high-risk patients. CONCLUSIONS: Ventilator support and intensive care for acute respiratory failure due to pneumonia or acute respiratory distress syndrome are relatively cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival < or =50%, the cost per QALY is more than threefold greater at >$100,000.

APACHE↗
PubMed1999

The concept of quality of life of dying persons in the context of health care.

Considerable research has addressed quality of life and quality of care; however, it has not addressed adequately the experiences of patients and their families at the end of life. Health care may have a greater effect on quality of life during the dying process than it normally does. Building on research and expert review, a conceptual framework is presented that specifies and integrates quality of life and quality of health care indicators. Five main concepts include patient/family context, structure of care, process of care, satisfaction with care, and quality and length of life. Patient and family perspectives are considered. The framework emphasizes quality of life, thus detailed definitions of each quality of life domain are provided. The goal is to facilitate development of a comprehensive set of measures to describe the quality of life of dying persons and evaluate the care they receive, to be used to improve end-of-life care.

Attitude to Death↗
PubMed1998

The Medicare hospice benefit's influence on dying in nursing homes.

For dying nursing home residents, the prevalence of symptoms and care utilization prior to death has yet to be empirically described for a population-based sample. Yet, related work has suggested that the quality of care for dying nursing home residents is less optimal. The provision of Medicare hospice care in nursing homes offers a means for improving terminal care in nursing homes. However, other than controversial findings emanating from the U.S. Office of Inspector General's (OIG's) hospice studies, there is a dearth of evaluative research on the comparative costs and the benefits of Medicare hospice care in nursing homes. In this article, we discuss current knowledge concerning the dying experience of nursing home residents and of the influence of the Medicare hospice benefit in nursing homes. In doing so, we critique the OIG's study of hospice care in nursing homes and we raise concerns regarding access to the Medicare hospice benefit in nursing homes. We conclude by delineating the research needed to more fully understand the dying experience of nursing home residents and the influence of Medicare hospice care provision on this experience.

Journal Article↗
PubMed1998

Can we afford comprehensive, supportive care for the very old?

OBJECTIVE: To address the question, "Is there enough overuse of Medicare reimbursement to hospitals that reallocation of excess could provide sufficient funds to enhance home care and community services?" DESIGN: Simulation using data from the Medicare Current Beneficiary Survey (MCBS) to estimate dollars that might be reallocated from hospital reimbursement. PARTICIPANTS: A total of 3577 persons aged 80 and older in a stratified sample of Medicare beneficiaries interviewed in September 1992 in the MCBS. MEASUREMENTS: We ranked the United States hospital service areas' (HSAs) Medicare hospital discharge rates. We assigned the beneficiaries in the MCBS to the HSAs based on their residence zip codes. The hospitalization expenditures and mortality rates of MCBS respondents living in HSAs in each quartile were compared. RESULTS: By reducing hospital utilization to the mean level now used by the lowest quartile of HSAs, $560 would be saved per Medicare beneficiary aged 80 or older (P=.004) with no difference in mortality rates. These savings could purchase 40 visiting nurse visits per year for those in need. Potential savings would be $152 per Medicare beneficiary if hospital utilization were reduced from that used by the highest quartile to the level of the lower three quartiles of HSAs, enough to purchase about 11 additional visiting nurse visits. CONCLUSION: This simulation suggests that the very old might safely receive less hospital care. Because relatively few older people need home and community services in a year, these per capita savings could be reallocated to purchase many services for those having the greatest need.

Aged↗
PubMed1997

Patient preferences for communication with physicians about end-of-life decisions. SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment.

BACKGROUND: Physicians are frequently unaware of patient preferences for end-of-life care. Identifying and exploring barriers to patient-physician communication about end-of-life issues may help guide physicians and their patients toward more effective discussions. OBJECTIVE: To examine correlates and associated outcomes of patient communication and patient preferences for communication with physicians about cardiopulmonary resuscitation and prolonged mechanical ventilation. DESIGN: Prospective cohort study. SETTING: Five tertiary care hospitals. PATIENTS: 1832 (85%) of 2162 eligible patients completed interviews. MEASUREMENTS: Surveys of patient characteristics and preferences for end-of-life care; perceptions of prognosis, decision making, and quality of life; and patient preferences for communication with physicians about end-of-life decisions. RESULTS: Fewer than one fourth (23%) of seriously ill patients had discussed preferences for cardiopulmonary resuscitation with their physicians. Of patients who had not discussed their preferences for resuscitation, 58% were not interested in doing so. Of patients who had not discussed and did not want to discuss their preferences, 25% did not want resuscitation. In multivariable analyses, patient factors independently associated with not wanting to discuss preferences for cardiopulmonary resuscitation included being of an ethnicity other than black (adjusted odds ratio [OR], 1.48 [95% CI, 1.10 to 1.99), not having an advance directive (OR, 1.35 [CI, 1.04 to 1.76]), estimating an excellent prognosis (OR, 1.72 [CI, 1.32 to 2.59]), reporting fair to excellent quality of life (OR, 1.36 [CI, 1.05 to 1.76]), and not desiring active involvement in medical decisions (OR, 1.33 [CI, 1.07 to 1.65]). Factors independently associated with wanting to discuss preferences for resuscitation but not doing so included being black (OR, 1.53 [CI, 1.11 to 2.11]) and being younger (OR, 1.14 per 10-year interval younger [CI, 1.04 to 1.25]). CONCLUSIONS: Among seriously ill hospitalized adults, communication about preferences for cardiopulmonary resuscitation is uncommon. A majority of patients who have not discussed preferences for end-of-life care do not want to do so. For patients who do not want to discuss their preferences, as well as patients with an unmet need for such discussions, failure to discuss preferences for cardiopulmonary resuscitation and mechanical ventilation may result in unwanted interventions.

Adult↗
PubMed1997

Changes in hospitalization associated with introducing the Resident Assessment Instrument.

OBJECTIVE: To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI). SAMPLE: Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI. METHODS: Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and casemix variables, and having a DNR order in the chart. RESULTS: A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53-1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%). CONCLUSIONS: Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.

Activities of Daily Living↗
PubMed1997

Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

OBJECTIVE: To assess the effectiveness of written advance directives (ADs) in the care of seriously ill, hospitalized patients. In particular, to conduct an assessment after ADs were promoted by the Patient Self-Determination Act (PSDA) and enhanced by the effort to improve decision-making in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), focusing upon the impact of ADs on decision-making about resuscitation. DESIGN: Observational cohort study conducted for 2 years before (PRE) and for 2 years after (POST) the PSDA, with a randomized, controlled trial of an additional intervention to improve decision-making after PSDA (POST+SUPPORT). SETTING: Five teaching hospitals in the United States. PATIENTS: A total of 9105 seriously ill patients treated in five teaching hospitals. INTERVENTIONS: The PSDA mandated patient education about ADs at hospital entry and documentation of ADs in the medical record. The SUPPORT intervention, in addition, provided a nurse to facilitate communication among patients, surrogates, and physicians about preferences for and outcomes of treatment alternatives and, when clinically appropriate, to encourage completion and utilization of ADs. MEASUREMENTS: Interviews were conducted with patients, surrogates, and attending physicians about awareness, completion, and impact of ADs. Medical records were reviewed for discussion about preferences concerning resuscitation, timing and writing of "Do Not Resuscitate" (DNR) orders, evidence of ADs, and the use or forgoing of resuscitation at the time of death. RESULTS: In the three cohorts, PRE, POST, and POST+SUPPORT, average age was 63. One-quarter of patients died during the initial hospitalization, one-half were dead within 6 months, and one-half were unconscious for their last 3 days. Before the PSDA (PRE), 62% were familiar with a living will, and 21% had an AD. These rates were similar for the POST and POST+SUPPORT cohorts. Just 36 (6%) of these directives were mentioned in the medical records for PRE, but a stable 35% were documented for POST, and POST+SUPPORT had an increasing rate averaging 78% (P < .001). As previously reported for PRE patients, the POST patients with and without ADs had no significant differences in the rates of medical record documentation of discussions about resuscitation (33% vs 38%, POST without AD vs POST with AD), DNR orders among those who wanted to forgo resuscitation (54% vs 58%), and attempted resuscitations at death (17% vs 9%). The POST+SUPPORT patients had similar results, with no evidence that the intervention enhanced the effect of ADs on these three measures of resuscitation decision-making. Patients with ADs more often reported that preferences about resuscitation were discussed with a physician (e.g., for POST patients, 30% for those with no AD and 43% for those with an AD, P < .05). Only 12% of patients with ADs had talked with a physician when completing the AD. Only 42% reported ever having discussed the AD with their physician. By the second study week, only one in four physicians was aware of patients' ADs. CONCLUSIONS: In these seriously ill patients, ADs did not substantially enhance physician-patient communication or decision-making about resuscitation. This lack of effect was not altered by the PSDA or by the enhanced efforts in SUPPORT, although these interventions each substantially increased documentation of existing ADs. Current practice patterns indicate that increasing the frequency of ADs is unlikely to be a substantial element in improving the care of seriously ill patients. Future work to improve decision-making should focus upon improving the current pattern of practice through better communication and more comprehensive advance care planning.

Advance Care Planning↗
PubMed1997

The illusion of end-of-life resource savings with advance directives. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

OBJECTIVE: Would increasing the documentation of advance directives (ADs) lead to a reduction in resource utilization? We examined this question by conducting three secondary analyses: (1) we tested for a change in resource use among those who died in the hospital at a time before and after an intervention that increased the documentation of ADs in the medical record; (2) we replicated analyses of published studies that reported an association of chart documentation of ADs and hospital resource use; and (3) we examined whether a potential explanation of the observed association is biased documentation of ADs among patients who have completed an AD. DESIGN: Replication of analysis of previous published studies using data from a prospective cohort study and block-randomized controlled trial. SETTING: Five teaching hospitals in the United States. PATIENTS: A total of 9105 seriously ill patients were enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), including 4301 patients in the 2 years (1989-91) before the Patient Self-Determination Act (PSDA) and 4804 in the 2 years (1992-94) after the PSDA implementation, with 2652 patients receiving the intervention and 2152 serving as controls. INTERVENTIONS: The SUPPORT intervention provided a nurse to facilitate communication among patients, surrogates, and physicians about preferences for and outcomes of treatments. Documenting existing advance directives was also one of this nurse's tasks. The Patient Self-Determination Act required that health care institutions inquire about and document existing advance directives at the time of hospital admission. MEASUREMENT: Hospital resource use was derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1994 dollars. RESULTS: Chart documentation of existing advance directives at the time of study admission increased with both the PSDA and the SUPPORT intervention. We found that intervention patients were more likely to have pre-existing ADs documented. Despite this increase, there was no corresponding change in hospital resource use for those who died during the enrollment hospitalization. Replication of analyses from published studies using data from the block randomized controlled trial found that ADs documented by the third day of serious illness were associated with a 23% reduction in hospital resource use among control patients ($21,284 with ADs documented compared with $26,127 without, 95% CI 1-48% reduction). However, this association was not observed among intervention patients, who had more pre-existing ADs documented in the medical record. Intervention patients with early documentation of ADs showed a trend toward greater cost ($28,017 compared with $24,178 among those without AD documentation, 95% CI 0-25% increase). The rate of documentation and characteristics of those with documentation differed between control and intervention patients. Intervention patients were more likely (as reported by patient or surrogate interview) to have ADs documented in the medical record by the third day (55% vs 32%, P < .001). In contrast to intervention patients, control patients who were older, less wealthy, less educated, more likely to prefer to forgo CPR, and more likely to want life-sustaining treatment limited had their ADs documented. These associations were not found among intervention patients when comparison was made between those with and those without an AD documented in the medical record. CONCLUSION: Increasing the documentation of pre-existing ADs was not associated with a reduction in hospital resource use. ADs documented without further intervention by the third day of a serious illness were associated with decreased hospital resource use. However, we did not find this association with an intervention that increased AD documentation. One potential explanation of these findings is that classification of those with an AD was based on cha

Advance Directives↗
PubMed1996

Choices of seriously ill patients about cardiopulmonary resuscitation: correlates and outcomes. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

PURPOSE: For patients hospitalized with serious illnesses, we identified factors associated with a stated preference to forgo cardiopulmonary resuscitation (CPR), examined physician-patient communication about these issues, and determined the relationship of patients' preferences to intensity of care and survival. PATIENTS AND METHODS: The study was a cross-sectional evaluation of patient preferences. The setting was five geographically diverse academic acute-care medical centers participating in the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) project. Study participants were hospitalized patients > or = 18 years of age with 1 of 9 serious illnesses who were interviewed between days 3 and 6 after qualifying for the study. Using standardized interviews, patients provided information on demographics, preferences for CPR and other treatments, quality of life, functional status, perceptions of prognosis, and whether the patient had discussed CPR preferences with his or her physician. Data abstracted from the medical record included physiologic measures, therapeutic intensity, whether CPR was provided, and whether there was a do-not-resuscitate order. RESULTS: Of 1,995 eligible patients, 84% were interviewed (mean age 62 years, 58% men, inhospital mortality 7%, 6-month mortality 33%). Of the respondents, 28% did not want CPR. Factors associated independently with not wanting CPR included: hospital site; diagnosis; being older; being more functionally impaired; and patient perception of a worse prognosis. Only 29% of patients had discussed their preferences with their physician; 48% of those who did not want CPR reported such discussions. After adjusting for illness severity and factors associated with CPR preferences, patients not wanting CPR had lower intensity of care; similar inhospital mortality; and higher mortality at 2 and 6 months following study entry. CONCLUSIONS: The diagnosis, patients' perception of the prognosis, and hospital site were significantly associated with patients' resuscitation preferences after adjusting for patient demographics, severity of illness, and functional status. The rate of discussing CPR was low even for patients who did not want CPR. Patient preferences not to receive CPR were associated with a small decrease in intensity of care but no difference in hospital survival.

Aged↗
PubMed1995

Identification of comatose patients at high risk for death or severe disability. SUPPORT Investigators. Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVE: To develop and validate a simple prognostic scoring system to identify patients in nontraumatic coma at high risk for poor outcomes using data available early in the hospital course. DESIGN: Prospective cohort study. SETTING: Five geographically diverse academic medical centers. PATIENTS: A total of 596 patients in nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), including 247 in the model derivation set and 349 in the model validation set. MAIN OUTCOME MEASURES: Death and severe disability by 2 months. MAIN RESULTS: For the 596 patients studied (median age, 67 years; 52% female), the primary cause of coma was cardiac arrest in 31% and cerebral infarction or intracerebral hemorrhage in 36%. At 2 months 69% had died, 20% had survived with known severe disability, 8% were known to have survived without severe disability, and 3% survived with unknown functional status. Five clinical variables available on day 3 after enrollment were associated independently with 2-month mortality: abnormal brain stem response (adjusted odds ratio [OR] = 3.2; 95% confidence interval [CI], 1.3 to 8.1), absent verbal response (OR = 4.6; 95% CI, 1.8 to 11.7), absent withdrawal response to pain (OR = 4.3; 95% CI, 1.7 to 10.8), creatinine level greater than or equal to 132.6 mumol/L (1.5 mg/dL) (OR = 4.5; 95% CI, 1.8 to 11.0), and age of 70 years or older (OR = 5.1; 95% CI, 2.2 to 12.2). Mortality at 2 months for patients with four or five of these risk factors was 97% (58/60; 95% CI, 88% to 100%) in the validation set. Brain stem and motor responses best predicted death or severe disability by 2 months. For patients with either an abnormal brain stem response or absent motor response to pain, the rate of death or severe disability at 2 months was 96% (185/193; 95% CI, 92% to 98%) in the validation set. CONCLUSIONS: Five readily available clinical variables identify a large subgroup of patients in nontraumatic coma at high risk for poor outcomes. This risk stratification approach offers physicians, patients, and patients' families information that may prove useful in patient care decisions and resource allocation.

APACHE↗
PubMed1995

Predicting future functional status for seriously ill hospitalized adults. The SUPPORT prognostic model.

OBJECTIVE: To develop a model estimating the probability of an adult patient having severe functional limitations 2 months after being hospitalized with one of nine serious illnesses. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: 1746 patients (model development) who survived 2 months and completed an interview, selected from 4301 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT); independent validation sample of 2478 patients. MEASUREMENTS AND MAIN OUTCOMES: Patient function 2 months after admission categorized as absence or presence of severe functional limitations (defined as Sickness Impact Profile scores > or = 30 or as activities of daily living scores > or = 4 [levels that require near-constant personal assistance]). A logistic regression model was constructed to predict severe functional limitation. RESULTS: One third (n = 590) of patients who were interviewed at 2 months had severe functional limitations. Changes in functional status were common: Of those with no baseline dependencies (not dependent on personal assistance), 21% were severely limited at 2 months; of those with 4 or more baseline limitations, 30% had improved. The patient's ability to do activities of daily living was the most important predictor of functional status. Physiologic abnormalities, diagnosis, days in hospital, age, quality of life, and previous exercise capacity also contributed substantially. Model performance, assessed using receiver-operating characteristic curves, was 0.79 for the development sample and 0.75 for the validation sample. The model was well calibrated for the entire risk range. CONCLUSIONS: Functional outcome varied substantially after hospitalization for a serious illness. A small amount of readily available clinical information can estimate the probability of severe functional limitations.

Activities of Daily Living↗
PubMed1995

Surrogates' predictions of seriously ill patients' resuscitation preferences.

BACKGROUND: Seriously or terminally ill patients are frequently incapacitated and unable to express their preferences regarding cardiopulmonary resuscitation (CPR). In this situation, family members or other surrogate decision makers are often asked whether they believe the patient would want to be resuscitated. We evaluated the concordance of patient CPR preferences and surrogate perceptions of the patient preferences in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a large, multicenter study of seriously ill hospitalized patients. METHODS: We compared patient preferences and surrogate perceptions in 1226 pairings in which both patient and surrogate responded to CPR decision questions. We also examined factors that might influence patient-surrogate concordance. RESULTS: Twenty-nine percent of patients with paired data did not want to be resuscitated; 26% of surrogates did not believe the patient they represented would want to be resuscitated. Within pairs, the overall exact agreement with respect to CPR decisions was 74%. For patients favoring CPR, only 16% of the surrogates misconstrued the patient's wishes. For patients who did not want to be resuscitated, however, 50% of the surrogates did not reflect the patient's wishes. If patients reported telling surrogates their CPR preference, concordance was significantly improved if the surrogate believed the patient did not want to be resuscitated and was significantly worsened if the surrogate believed the patient wanted CPR. This finding is likely an artifact of patients being more likely to report their preference to surrogates if that preference was not to be resuscitated. CONCLUSIONS: Surrogates' perceptions of patient CPR preferences are often inaccurate, particularly for those patients who do not want to be resuscitated. Methods to improve communication between patients and surrogates on CPR preferences should be developed and evaluated.

Adult↗
PubMed1994

The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.

BACKGROUND: Studies suggest that a majority of elderly patients would want to undergo cardiopulmonary resuscitation (CPR) if they had a cardiac arrest. Yet few studies have examined their preferences after clinicians have informed them about the outcomes of CPR. METHODS: To study older patients' preferences regarding CPR, we interviewed as many ambulatory patients as possible in one geriatrics practice in Denver from August 1, 1991, through July 31, 1992. RESULTS: A total of 371 patients at least 60 years of age were eligible; 287 completed the interview (mean age, 77 years; range, 60 to 99). When asked about their wishes if they had cardiac arrest during an acute illness, 41 percent opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (10 to 17 percent), 22 percent opted for CPR. Only 6 percent of patients 86 years of age or older opted for CPR under these conditions. When asked about a chronic illness in which the life expectancy was less than one year, 11 percent of the 287 patients opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (0 to 5 percent), 5 percent said they would want CPR. CONCLUSIONS: Older patients readily understand prognostic information, which influences their preferences with respect to CPR. Most do not want to undergo CPR once a clinician explains the probability of survival after the procedure.

Advance Directives↗