High quality palliative care and communication in older patients improves quality of care, patient and family satisfaction, and costs of care. One important component of communication is discussing cardiopulmonary resuscitation (CPR), as this is required for every hospital admission and most older patients have not discussed CPR prior to hospitalization. Unfortunately, these conversations are often inadequate and leave patients and families feeling burdened, stressed, and concerned. Outcomes after in-hospital CPR in chronically ill older patients continue to be very poor, despite decades of efforts toward improvement. Our prior work has shown that an increasing proportion of hospitalized older adults receive CPR before death with continued poor survival rates and that the longer-term benefits of CPR are decreasing with fewer patients discharged home after CPR. Additionally, when compared to those without chronic illness, older patients with advanced chronic illness have significantly worse hospital discharge and long-term survival after CPR, and among survivors, experience more hospital readmissions until death and are less likely to be discharged home. We have recently successfully completed two pilot studies of a novel informed assent approach to discussing CPR, a specific communication framework whereby older patients who meet specific criteria and do not wish to remain alive at all costs are informed that they should not receive CPR. Our preliminary data demonstrate that this intervention is feasible and well-received by patients, family members, and physicians. Additionally, among patients who wanted CPR at enrollment in our pilot RCT, significantly more patients receiving the intervention changed their preferences to no CPR than did control patients. We therefore propose a phase II proof-of-concept RCT comparing our innovative informed assent intervention versus usual care with attention control for older hospitalized adults with severe life-limiting illness or functional or cognitive impairment, enrolling patients and family members. We hypothesize that informed assent will improved quality of and satisfaction with communication about CPR; reduce the burden of potentially harmful CPR discussions, including reduced patient and family symptoms of depression, anxiety and decisional regret; and reduce intensity of care and health care utilization. The research team proposing this project, led by an Early Stage Investigator, has extensive experience with RCTs and patient recruitment, as well as years of successful collaboration, including recent completion of two pilot studies of informed assent. They are well positioned to conduct this study that aims to change the paradigm of CPR discussions with older adults unlikely to benefit from CPR. If effective, this informed assent intervention has the potential to revolutionize discussions about CPR with chronically ill older patients.
High quality clinician-patient communication with older patients who have life-limiting illness, or functional or cognitive impairment, and their families s particularly important. This is especially true with regards to cardiopulmonary resuscitation (CPR), as outcomes in such patients are extremely poor, yet provision of CPR is the default and the communication methods commonly used in clincal settings may cause increased anxiety and stress. This research proposal is a proof-of-concept randomized controlled trial of a novel informed assent communication intervention regarding CPR in older patients with life-limiting illness or severe functional or cognitive impairment and their families. This RCT challenges the paradigm of our current perceptions of and approach to CPR discussions and seeks to demonstrate that family- and patient-assessed quality of and satisfaction with communication about CPR can be improved. We also hypothesize that this intervention will reduce symptoms of depression, anxiety, and decisional regret among patients and family members; decrease time to do not resuscitate orders; and decrease health care utilization and intensity of care.
| Goodwin, Andrew J; Ford, Dee W (2018) Readmissions Among Sepsis Survivors: Risk Factors and Prevention. Clin Pulm Med 25:79-83 |
