From the Section of Cardiovascular Medicine, Department of Medicine and
the Section of Chronic Disease Epidemiology, Department of Epidemiology and
Public Health, Yale School of Medicine and the Yale-New Haven Hospital Center
for Outcomes Research and Evaluation, New Haven, Conn (H.M.K.); the Division
of General Medicine and Primary Care, Beth Israel Hospital, Boston, Mass
(R.S.P., M.B.H., R.B.D.); the Center for Gerontology and Health Care Research,
Brown University, Providence, RI (J.M.T.); the UCLA School of Medicine, UCLA
Medical Center, Los Angeles, Calif (P.B.); the Marshfield Medical Research
Foundation/Marshfield Clinic, Marshfield, Wis (S.K.B., H.V.); the Duke
University Medical Center, Durham, NC (R.M.C., L.H.M.); Case Western Reserve
University, MetroHealth Medical Center, Cleveland, Ohio (A.F.C.); George
Washington University Medical Center, Washington, DC (J.L.); and the
Department of Medicine, University of California, San Francisco, Calif (L.G.).
Correspondence to Harlan M. Krumholz, MD, Yale School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 06520-8025. E-mail harlan.krumholz{at}yale.edu
Methods and Results—Of 936 patients in this study, 215 (23%)
explicitly stated that they did not want to be resuscitated.
Significant correlates of not wanting to be resuscitated included older
age, perception of a worse prognosis, poorer functional status, and
higher income. The physician's perception of the patient's preference
disagreed with the patient's actual preference in 24% of the cases
overall. Only 25% of the patients reported discussing resuscitation
preferences with their physician, but discussion of preferences was not
significantly associated with higher agreement between the patient and
physician. Of the 600 patients who responded to the resuscitation
question again 2 months later, 19% had changed their preferences,
including 14% of those who initially wanted resuscitation (69 of 480)
and 40% of those who initially did not (48 of 120). The physician's
perception of the patient's hospital resuscitation preference was
correct for 84% of patients who had a stable preference and 68% of
those who did not.
Conclusions—Almost one quarter of patients hospitalized with
severe heart failure expressed a preference not to be resuscitated. The
physician's perception of the patient's preference was not accurate
in about one quarter of the cases, but communication was not associated
with greater agreement between the patient and the physician. A
substantial proportion of patients who did not want to be resuscitated
changed their minds within 2 months of discharge.
Until recently there has been very little information about
the resuscitation preferences of patients with severe congestive heart
failure. To address this issue in detail, we used data obtained as part
of the Study to Understand Prognoses and Preferences for Outcomes and
Risks of Treatments (SUPPORT) project,3 a
prospective multicenter study of prognoses and preferences for
treatment for severely ill patients, including individuals hospitalized
with an exacerbation of severe congestive heart failure (New York Heart
Association class IV, or clinical heart failure and an ejection
fraction <20%). In the SUPPORT project, patients and their
physicians were asked about the patient's health, quality of life,
daily activity level, functional status, prognosis, and resuscitation
preferences.
Phase 1 (1989 to 1991) of SUPPORT was designed to evaluate preferences,
decisions, and outcomes of severely ill hospitalized patients. Phase 2
(1992 to 1994) was a clinical trial of a program that provided
information about patient prognoses and preferences for end-of-life
care and a nurse-based intervention to facilitate communication. The
program failed to increase the frequency of DNR orders or to reduce the
number of days it took to write them. Furthermore, there were no
secular trends in DNR order writing during the study period (1989 to
1994). Thus, the data from both phases were combined for this
analysis.3
Patient Sample
Clinical Data
Patient Interviews
Functional status in the 2 weeks before admission was assessed by a
revised version of the Katz Activities of Daily Living
score8 on the basis of the ability to perform
bathing, dressing, toileting, transfer, continence, and feeding. A
summary score was calculated, with 0 indicating independence in all
categories. Activity status 2 weeks before admission was estimated by a
revised version of the Duke Activity Status
Index,8 which is a modification of the Specific
Activity Scale.9 Activity status was defined as
the ability of patients to perform personal, household, and
recreational activities associated with known metabolic
costs.
The question about resuscitation was as follows: "As you probably
know, there are a number of things that doctors can do to try to revive
someone whose heart has stopped beating, which usually includes a
machine to help breathing. Thinking of your current condition, what
would you want your doctors to do if your heart ever stops beating?
Would you want your doctors to try to revive you, or would you want
your doctors not to try to revive you?" Only patients who explicitly
and unequivocally answered negatively were classified as not wanting
resuscitation because, in practice, patients with an equivocal response
would be resuscitated. The test-retest reliability (exact agreement) of
this measure in the SUPPORT study, assessed within 24 hours of the
initial interview for a subsample of patients, was
93%.10
Physician Interview
Statistical Analysis
The first model predicted patient preferences not to be resuscitated.
The following variables were considered in the construction of the
model: age (years); sex; race; acute physiology score on hospital day
3; whether the patient lived alone before admission; activities of
daily living dependencies based on patient status 2 weeks before
admission; modified Duke Activity Status Index based on patient status
2 weeks before admission; number of comorbidities; the patient's
estimate of living for 2 more months; the patient's estimate of living
independently in 2 months; the patient's assessment of his
or her quality of life; and whether the patient reported that he or she
was a transplantation candidate. The model was adjusted for study site
and the patient's estimated probability of surviving 2
months on the basis of the SUPPORT prognostic
model.6 We repeated the procedure after excluding
patients who responded that they did not know about their resuscitation
preference.
The second model determined the factors most strongly associated with a
physician's perception that a patient did not want to be resuscitated.
There were 750 phase 1 and 2 patients who responded to the
resuscitation question and whose physicians were interviewed and
responded to the resuscitation question. To adjust for the physician's
preference if he or she were in the patient's situation, we restricted
the analysis to the 339 phase 1 patients with information on
their preferences and the matched physician perception questions
because that question was asked at a later time in phase 2.
The same method of model construction was used as above except that the
following additional variables were considered: the physician's
resuscitation preference if he or she were in the patient's condition;
the physician's perception of the patient's quality of life
(excellent, very good, good, fair, or poor); whether the physician was
a cardiologist; the physician's age; the physician's sex; the
physician's year of graduation from medical school; whether the
physician planned to care for the patient after hospital discharge; the
length of time that the physician had known the patient (
The agreement between patients' own reports of and the physicians'
estimates of these resuscitation preferences, prognoses, and quality of
life was evaluated by use of the kappa
coefficient.9 A kappa coefficient >0.40
represents a moderate or greater degree of agreement beyond
that expected by chance.11 The associations of
patient and physician characteristics with agreement between the
patient and the physician were tested with
For all analyses, when information on income or level of
education was not available, we imputed values using previously
described methods.12 When information on
functional status and activity status was not available from the
patients, we used calibrated surrogates' reports of the patients'
functional and activity status. When information was not available from
patients or their surrogates, we imputed
values.12
Patient Resuscitation Preferences
In a multivariable model (Table 2
Of the 936 patients in the sample, 600 also responded to the
resuscitation questions at 2 months after discharge. Overall, 19% did
not have a stable preference, including 14% of the patients (69 of
480) who initially expressed a preference for resuscitation and 40%
(48 of 120) who did not.
Physician Perceptions of Patient Preferences
In the multivariable analysis, the strongest independent
correlate of the physician's perception that the patient did not want
to be resuscitated was the physician's resuscitation preference if he
or she were in the patient's condition. Physicians who would not want
to be resuscitated if in the patient's condition commonly thought that
the patient would not want to be resuscitated (OR, 14.7; 95% CI, 4.2
to 51.9). Other factors that were associated with the physician's
perception that the patient did not want to be resuscitated included
older patient age (adjusted OR for each year, 1.08; 95% CI, 1.04 to
1.13); the physician's perception of the patient's view of his or her
quality of life as fair or poor compared with excellent, very good, or
good (adjusted OR, 3.65; 95% CI, 1.48 to 9.02); physician's
prognostic estimate of a worse chance for survival at 2 months
(adjusted OR for each percent decrease in predicted 2-month chance of
survival, 1.02; 95% CI, 1.00 to 1.04); and the patient's expressed
preference (to the interviewer) that he or she did not want to be
resuscitated (adjusted OR, 3.25; 95% CI, 1.50 to 7.04). Dropping the
variable describing the physician's preference if he or she were
in the patient's position from the model did not substantially affect
the association of the other independent variables with the
patient's preference.
Patient and Physician Agreement
Physicians did not correctly perceive their patient's resuscitation
preference in 24% of the cases (177 of 750; kappa=0.26). The
discordance between patients and physicians was in both directions, but
it was more likely to occur when the patient did not want to be
resuscitated: in 69 (9%) of the cases, physicians thought patients did
not want resuscitation when the patients did want it (or did not know),
and in 108 (14%) of the cases, physicians thought patients wanted
resuscitation when the patients did not want it (McNemar
statistic=8.59, P=0.003). Discordance between the patient's
resuscitation preference and the physician's perceptions of the
preference was strongly associated with the patient's age (Table 3
DNR Order
Resuscitation Preferences and Cardiac Arrest
Most of the time, physicians correctly predicted the patient's
resuscitation preference. Nevertheless, for about 1 in 4 patients,
physicians did not have an accurate perception of the patient's
resuscitation preference. However, physicians were much more likely to
have an accurate perception of the resuscitation preferences of
patients who subsequently did not change their minds. Among patients
with stable preferences, physicians did not accurately perceive the
preference in only 1 of every 6 patients. Lack of communication between
patients and their physicians may have been expected to contribute to
the disagreement. Despite the fact that these patients were very ill
and their physicians expected many of them to die within the next 2
months, we found that only about one quarter of the patients and
physicians reported that they had discussed resuscitation issues. This
lack of communication has been observed in other
settings,13 14 despite evidence that patients
want to have these discussions.15 However, we
found that the physician's perception of the patient's preference was
not more likely to be accurate among those who reported communicating
with the physician. Moreover, the SUPPORT intervention, designed to
improve communication about these issues between patients and
physicians, failed to change practice.
Despite the complexity of this issue, our study did reveal some
interesting findings. Except for patient age, the correlates of the
physician's belief that the patient did not want to be resuscitated
differed from those predictors of patients' preferences. The most
important predictor of the physician's belief that the patient did not
want to be resuscitated was the physician's own preference not to be
resuscitated if he or she were in the patient's condition. The
patient's preference not to be resuscitated was also a significant
predictor, as was the physician's perception of the patient's
prognosis and quality of life.
Although the age of the patient was an important factor associated with
both the patients' preferences for resuscitation and the physicians'
beliefs about the patients' resuscitation preferences, the physicians
may have placed greater emphasis on age than the patients did. The age
of the patient was strongly related to the likelihood of discordance
between patients and physicians. Older age was associated with a higher
likelihood that physicians would incorrectly perceive the patient's
resuscitation preference.
The physician's perception of the patient's quality of life was
associated with his or her belief about the patient's preference.
However, the patients' assessments of their own quality of life (with
a single-item question) were not related to their own resuscitation
preferences. Other studies have also found that the patient's quality
of life has not been related to resuscitation preferences. Among
patients who had experienced medical intensive care, Patrick and
colleagues16 found no significant association
between the willingness of patients to undergo intensive care and their
quality of life as measured by the Perceived Quality of Life Scale. In
another study among outpatients, Uhlmann and
Pearlman17 found that neither global quality of
life nor selected dimensions of quality of life, including aspects of
social, physical, emotional, and intellectual functioning, were
associated with resuscitation preferences.
These studies of quality of life and resuscitation preferences
suggest either that the instruments that measure quality of life are
not sensitive to factors that influence decisions about resuscitation
or that patients consider other factors when making this decision.
Zweibel18 has suggested that patients do not
consider abstract concepts such as current quality of life when making
decisions about life-sustaining therapy but rather focus on concrete
factors such as the presence and level of chronic pain, their immediate
prognosis, and their likelihood of self-care. This observation
regarding prognosis appears to be true of patients with severe
congestive heart failure.
Physician characteristics were generally not associated with the degree
of agreement with patient preferences. In particular, agreement was not
significantly associated with age, sex, year of graduation from medical
school, or whether the physician knew the patient for <1 week.
Interestingly, the characteristic that was significantly associated
with agreement was specialty, with cardiologists performing better than
the other physicians.
Our overall findings are very consistent with findings from the
overall SUPPORT population. In the study by Phillips and
colleagues,10 28% of the SUPPORT population was
reported not to want to be resuscitated. In their multivariable
analysis, patients with congestive heart failure were more
likely to want to be resuscitated. In the overall sample, as in our
group, study site, age, functional status, and perception of prognosis
were strong predictors of resuscitation preferences.
Although the patient's estimated prognosis by the SUPPORT
prognostic model and the physician emerged as important factors in
predicting resuscitation preferences, it is important to note that
heart failure may be inherently more unpredictable in its short-term
prognosis than many other conditions such as lung cancer. Lynn and
colleagues19 20 have shown that estimates of
prognosis for critically ill patients may not accurately predict which
patients with heart failure will die soon. Many patients with heart
failure may die of a fatal arrhythmia at a time when they are
clinically stable. Consequently, patients and physicians, acknowledging
the risk of sudden and unexpected death in this condition, may need to
discuss issues about death and treatment at a time that may not be
perceived as close to the time of death. If physicians and patients
wait until the short-term prognosis becomes so grave that death is
imminent, they may never have the opportunity to discuss these
issues.
An important finding of this study is the lack of stability of the
resuscitation preferences for many patients who initially did not want
to be resuscitated. Our findings are consistent with a recent
report that found that 80% of the overall SUPPORT cohort had stable
resuscitation preferences over 2 months.21 The
lack of stability may reflect initial uncertainty about the preference,
inaccurate classification by the initial assessment, or a change in
perspective or circumstance that led patients to reconsider their
initial preferences. Whatever the cause, physicians were more likely to
report accurately the preferences of the patients who did not change
their minds. This observation adds complexity to the study of physician
perceptions of patient preference. It is not clear that physician
discordance with patients who change their minds should be considered a
problem.
Study Limitations
In addition, although the interviews of the patients and
physicians were close in time, they were not simultaneous.
It is possible that preferences changed after the patient interview and
before the physician interview. This change may have caused some
physicians to appear not to know the preference of their patient and
overestimated the discordance. For the identification of factors
associated with this discordance, however, this misclassification would
have been expected to add noise, not bias.
It is also possible that the process of conducting this study may have
altered behaviors. Patients who consented to be interviewed about their
resuscitation preferences should have been motivated to discuss these
issues with their physicians and may have done so before the physician
interview. This effect may have increased the communication and
agreement between patients and their physicians. Other limitations of
the study include the possible misinterpretation of the questions by
ill patients and the possible lack of generalizability of our findings
to patients in other medical centers.
Received January 22, 1998;
revision received March 27, 1998;
accepted April 21, 1998.
2.
Bedell SE, Pelle D, Maher PL, Cleary PD.
Do-not-resuscitate orders for critically ill patients in the hospital.
JAMA. 1986;256:233–237.
3.
The SUPPORT Principal Investigators. A controlled
trial to improve care for seriously ill hospitalized patients.
JAMA. 1995;274:1591–1598.
4.
Murphy DJ, Knaus WA, Lynn J. Study population in
SUPPORT. J Clin Epidemiol. 1990;43(suppl):11S–28S.
5.
Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner
M, Bastos PG, Sirio CA, Murphy DJ, Lotring T, Damiano A, Harrell FE Jr.
The APACHE III prognostic system. Chest. 1991;100:1619–1636.
6.
Knaus WA, Harrell FE, Lynn J, Goldman L, Phillips RS,
Connors AF, Dawson NV, Fulkerson WJ Jr, Califf RM, Desbiens NA, Layde
P, Oye RK, Bellamy PE, Hakim RB, Wagner DP. The SUPPORT prognostic
model. Ann Intern Med. 1995;122:191–203.
7.
Phillips RS, Goldman L, Bergner M. Patient
characteristics in SUPPORT: activity status and cognitive function.
J Clin Epidemiol. 1990;43(suppl):33S–36S.
8.
Landefeld CS, Phillips RS, Bergner M. Patient
characteristics in SUPPORT: functional status. J Clin
Epidemiol. 1990;43:37S–39S.
9.
Goldman L, Hashimoto B, Cook EF, Loscalzo A.
Comparative reproducibility and validity of systems for assessing
cardiovascular functional class: advantages of a new
specific activity scale. Circulation. 1981;64:1227–1234.
10.
Phillips RS, Wenger NS, Teno JM, Oye RK, Youngner S,
Califf RM, Layde P, Desbiens NA, Connors AF, Lynn J. Choices of
seriously ill patients about cardiopulmonary resuscitation:
correlates and outcomes. Am J Med. 1996;100:128–137.[Medline]
[Order article via Infotrieve]
11.
Landis JR, Koch GG. The measurement of observer
agreement for categorical data. Biometrics. 1977;33:159–174.[Medline]
[Order article via Infotrieve]
12.
Phillips RS, Hamel MB, Teno JM, Bellamy P, Broste SK,
Califf RM, Vidaillet H, Davis RB, Muhlbaier LH, Connors AF, Lynn J,
Goldman L. Race, resource use and survival in seriously ill
hospitalized adults. J Gen Intern Med. 1996;11:387–396.[Medline]
[Order article via Infotrieve]
13.
Danis M, Patrick DL, Southerland LI, Green ML.
Patients' and families' preferences for medical intensive care.
JAMA. 1988;260:797–802.
14.
Kinsella TD, Stocking CB. Failed communication
about life support therapy: silent physicians and mute patients.
Am J Med. 1989;86:643–644.[Medline]
[Order article via Infotrieve]
15.
Frankl D, Oye RK, Bellamy PE. Attitudes of
hospitalized patients toward life support: a survey of 200 medical
inpatients. Am J Med. 1989;86:645–648.
16.
Patrick DL, Danis M, Southerland LI, Hong G. Quality of
life following medical intensive care. J Gen Intern
Med. 1988;3:218–223.[Medline]
[Order article via Infotrieve]
17.
Uhlmann RF, Pearlman RA. Perceived quality of life and
preferences for life-sustaining treatment in older adults. Arch
Intern Med. 1991;151:495–497.
18.
Zweibel NR. Measuring quality of life near the end of
life. JAMA. 1988;260:839–840.
19.
Lynn J, Harrell FE, Cohn F, Hamel MB, Dawson NV,
Wu AW. Defining the "terminally ill": insights from SUPPORT.
Duq Law Rev. 1996;35:311–336.
20.
Lynn J, Harrell FE, Cohn F, Wagner DP, Connors AF.
Prognoses of seriously ill hospitalized patients on the days before
death: implications for patient care and public policy. New
Horiz. 1997;5:56–61.[Medline]
[Order article via Infotrieve]
21.
Rosenfeld KE, Wenger NS, Phillips RS, Connors AF,
Dawson NV, Layde P, Califf RM, Liu H, Lynn J, Oye RK, for the SUPPORT
Investigators. Factors associated with change in resuscitation
preference of seriously ill patients. Arch Intern Med. 1996;156:1558–1564.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Resuscitation Preferences Among Patients With Severe Congestive Heart Failure
Results From the SUPPORT Project
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—We sought to describe the
resuscitation preferences of patients hospitalized with an exacerbation
of severe congestive heart failure, perceptions of those preferences by
their physicians, and the stability of the preferences.
Key Words: resuscitation • patients • heart failure
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
The end of life
for patients with severe congestive heart failure is often
characterized by repeated hospitalizations and a progressively
declining quality of life. Although many patients with poor prognoses
refuse medical interventions,1 patients with
severe congestive heart failure usually receive maximal medical therapy
until death. The prevalence of do-not-resuscitate (DNR) orders in
patients with severe congestive heart failure has been reported to be
<5%,1 and patients with congestive heart
failure who die in the hospital commonly undergo
cardiopulmonary resuscitation.2 Although
it is not known why DNR orders are written infrequently in this
population, physicians discuss resuscitation issues less often with
patients with severe congestive heart failure than with patients who
have other terminal diseases such as AIDS or
cancer.1
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Study Design
Patients in SUPPORT had 1 of 9 high-mortality conditions: acute
exacerbation of congestive heart failure, acute respiratory failure,
acute exacerbation of chronic obstructive pulmonary disease,
chronic liver disease, nontraumatic coma, colon cancer metastatic to
liver, stage III/IV non–small cell carcinoma of the lung, multiple
organ system failure with malignancy, and multiple organ failure and
sepsis.4 Patients, their designated surrogate
decision makers (usually family members), and physicians were
interviewed at several points in the patient's hospitalization. The
study was conducted at 5 hospitals: Beth Israel Hospital, Boston, Mass;
MetroHealth Medical Center, Cleveland, Ohio; Duke University Medical
Center, Durham, NC; Marshfield Clinic/St Joseph's Hospital,
Marshfield, Wis; and the University of California School of Medicine,
Los Angeles, Calif. The coordinating center was the Intensive Care Unit
Research Unit at the George Washington University Medical Center.
Subjects in this analysis were restricted to patients
with an acute exacerbation of symptoms of chronic congestive heart
failure as the primary reason for hospital admission or transfer to an
intensive care unit and at least 1 of the following 3 conditions: (1) a
history of severe congestive heart failure at baseline (New York Heart
Association class IV) despite being treated medically with 2 or more of
the following classes of drugs: diuretics, vasodilators, and
ACE inhibitors; (2) a definite history of New York Heart
Association class IV congestive heart failure at hospital admission; or
(3) documentation of a left ventricular ejection fraction
20%. Patients were excluded from the study if they had any of the
following conditions: severe chronic obstructive pulmonary
disease, high output congestive heart failure, septic shock, primary
acute renal failure, circulatory overload caused by excessive
administration of fluids, cardiac surgery scheduled within 24 hours,
congestive heart failure caused by valvular heart disease, or a
thoracotomy on the same admission and before study entry.
Clinical data were obtained by chart review and included cardiac
history; comorbid conditions; information required to calculate an
acute physiology score (based on the APACHE III scoring
system5); and documentation of decisions related
to the use of life-sustaining therapy, including the presence of a DNR
order. The acute physiology score, measured on study days 1, 3, 7, 14,
and 25, is a composite of information about heart rate; mean blood
pressure; temperature; respiratory rate; partial pressure of oxygen;
arterial-alveolar oxygen gradient; hematocrit; white blood
cell count; creatinine; urine output; blood urea nitrogen;
sodium; albumin; bilirubin; glucose; arterial blood
pH; and neurological abnormalities. A previously published model of
180-day mortality in SUPPORT was used to determine an "objective"
measure of the patient's prognosis.6 This model
includes the following variables: diagnosis, age, number of days in
the hospital before study entry, presence of cancer, neurological
function, and 11 physiological measures.
Patients were approached to be interviewed between days 3 and 6
after enrollment in the study and 2 months after discharge. Patients
passing the test of cognitive function7 were then
questioned about their resuscitation preferences, probability of
survival, functional status, symptoms, quality of life, and
sociodemographics. Patients were asked, "What are the chances that
you will live for 2 months or more (and 6 months or more) if the
current plan of care stays the same?" Patients also were asked,
"What are the chances that you will be able to take care of yourself
2 months (and 6 months) from now?" Patients were asked to rate their
quality of life ("How would you rate the overall quality of your life
at present?") on a 5-point scale from excellent to poor.
The physician chiefly responsible for each study patient was
interviewed. The interviews collected information about physician
characteristics, perceptions of their patient's preferences, and
perceptions of their patient's prognosis and quality of life.
Physicians were asked, "What do you think the patient would want you
to do if he or she had a cardiopulmonary arrest?"
In bivariable analyses, Student's t test
was used to compare continuous, normally distributed
variables, and nonparametric tests were used
to compare variables that were not normally distributed.
In the multivariable analysis, 2 stepwise
multiple logistic regression models were developed.
Variables were retained in the model if the regression
coefficient was significantly associated at the 
=0.10 on
the basis of the Wald test. Each model was
adjusted for study site by including indicator
variables. 1 week
versus >1 week); the physician's perception of the likelihood that
the patient would live 2 months (0% to 100%); and the physician's
perception of the patient's belief about his or her quality of life
(excellent, very good, good, fair, or poor). We repeated the procedure
after excluding the variable describing what the physician would do
if he or she were in the patient's position. 
2
tests.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Study Sample
Phases 1 and 2 of SUPPORT enrolled 9105 subjects (4301 patients
were enrolled in phase 1 and 4804 in phase 2), including 1404 patients
with an exacerbation of chronic congestive heart failure. The study
sample consisted of 936 patients with congestive heart failure who
participated in the study interview and responded to the question about
resuscitation. The interviewed patients were younger, were less ill,
and had a lower in-hospital mortality than patients who did not
participate in the interview, but they were not different with respect
to sex, history of myocardial infarction, number of comorbid
conditions, or ejection fraction.
Among the study sample, 215 (23%) of 936 patients did not wish to
be resuscitated in the case of a cardiac arrest, 646 (69%) definitely
did want to be resuscitated, and 75 (8%) were unsure whether they
wanted a full resuscitation effort. Factors associated with
resuscitation preference are summarized in Table 1
.
View this table:
[in a new window]
Table 1. Bivariable Analysis of Factors
Associated With Patients Not Wanting CPR* (n=936) ), a
strong predictor of the patient's preference not to be resuscitated
was the patient's perception of a worse prognosis (expressed as
likelihood of living 2 months). Other factors that were significantly
associated with not wanting to be resuscitated included worse activity
status in the 2 weeks before admission, higher income, and older age.
The model did not change substantially if patients who expressed
uncertainty about their resuscitation preferences were excluded.
View this table:
[in a new window]
Table 2. Logistic Regression Model for Predicting Patient
Preference for Not Wanting CPR (n=919)
Of the 936 patients in our study sample, 475 were in phase 1 of
SUPPORT. Of these, 339 patients had matching physician interviews with
complete data collection for the analysis, which were conducted
between days 3 and 6 (see "Methods"). In 62 (18%) of the
interviews, physicians believed that their patients did not want to be
resuscitated.
Only 25% of the patients (236 of 936) with heart failure who
responded to the resuscitation question reported having told their
physician about their resuscitation preferences. Of the 936 patients in
the study sample, 750 had a matching physician interview. The mean time
between the patient and physician interviews was 0.1 days
(interquartile range, -1 to 1 day). ). The frequency of disagreement between
patients and their physicians increased from 17% among patients 40 to
64 years of age to 29% among patients 
75 years
(P<0.001). Cardiologists were significantly more likely
than noncardiologists to agree with the patient's preference
(P<0.001). Physicians were not more likely to understand
patients' preferences when patients reported discussing their
preferences with their physicians. Of the 392 patients with a stable
resuscitation preference over 2 months and a matched physician
interview (92 did not have a physician interview), the physician's
perception of the patient's preference disagreed with the patient's
actual preference in 16% of the cases compared with 42% for those
whose preference changed over time.
View this table:
[in a new window]
Table 3. Agreement Between Patients and Their Physicians
Concerning Resuscitation
Of the entire study sample of 1404 patients with an exacerbation
of congestive heart failure, 241 (17%) had a DNR order written in the
hospital chart before discharge. The median time between study
admission and the DNR order among those who had a DNR order written
after study admission was 2 days (range, 0 to 88 days). Of the 936
patients who answered the resuscitation question, 86 (9%) had a DNR
order by study day 6 and 111 (12%) by hospital discharge. Of the 215
patients who expressed a preference not to be resuscitated, 52 (24%)
had a DNR order by study day 6 and 57 (27%) by hospital discharge. Of
the 721 patients who stated that they would want to be resuscitated or
were unsure, 34 (5%) had a DNR order by study day 6 and 54 (7%) by
hospital discharge.
Of the 936 patients in our study sample, 42 had cardiac arrest
after their day 3 interview. The median time to the cardiac arrest was
4 days. Of these 42 patients, 31 had expressed a preference for
resuscitation and 19 had resuscitation attempts. The 12 patients who
were not resuscitated had a DNR order written before the cardiac
arrest. Of the 19 for whom resuscitation had been attempted, 10 were
discharged alive; the others died in the hospital. Among the 42
patients with cardiac arrest, 11 had stated that they did not want to
be resuscitated. Of the 11 patients who stated that they did not want
to be resuscitated, 5 had DNR orders written and were not resuscitated.
The remaining 6 patients had resuscitation attempted, and 1 patient
survived to hospital discharge.
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
This prospective study of resuscitation preferences in patients
who were admitted with an exacerbation of severe heart failure reveals
the marked complexity of this issue. About one quarter of the patients
who were interviewed expressed a preference not to be resuscitated in
the event of a cardiac arrest. This preference was expressed to an
impartial interviewer between 3 and 6 days after being enrolled in the
study. Several predictors of this preference were identified in a
multivariable analysis, including study site, older age,
more limited functional status, a lower estimate of prognosis by the
patient, and higher income.
This study has several important limitations. Any study of
resuscitation preferences is inherently difficult. The patients in this
study were interviewed by individuals who had no relationship with them
and were not involved in their care. There may be concerns that
patients responded differently to the interviewers than they did with
their physicians. In addition, the question used to assess
resuscitation preferences may not reflect many of the nuances of this
issue. Many physicians may have difficulty with the question because
they consider many levels of resuscitation to exist. Also, physicians
may consider the issue of resuscitation differently, depending on the
circumstance in which the cardiac arrest occurs.
Acknowledgments
Dr Krumholz is a Paul Beeson Faculty Scholar. This work was
supported by the Robert Wood Johnson Foundation. The opinions and
findings contained in this article are those of the authors and do not
necessarily represent the views of the Robert Wood Johnson
Foundation or its Board of Trustees.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
1.
Wachter RM, Luce JM, Hearst N, Lo B. Decisions
about resuscitation: inequities among patients with different diseases
but similar prognoses. Ann Intern Med. 1989;111:525–532.
This article has been cited by other articles:
 |
|
 |
|
  P. D. Levy, H. Ye, S. Compton, P. S. Chan, G. L. Larkin, R. D. Welch, and for the American Heart Association National Regist Factors Associated With Neurologically Intact Survival for Patients With Acute Heart Failure and In-Hospital Cardiac Arrest Circ Heart Fail, November 1, 2009; 2(6): 572 - 581. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Jaarsma, J. M. Beattie, M. Ryder, F. H. Rutten, T. McDonagh, P. Mohacsi, S. A. Murray, T. Grodzicki, I. Bergh, M. Metra, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology Eur J Heart Fail, May 1, 2009; 11(5): 433 - 443. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. A. Hunt, W. T. Abraham, M. H. Chin, A. M. Feldman, G. S. Francis, T. G. Ganiats, M. Jessup, M. A. Konstam, D. M. Mancini, K. Michl, et al. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation J. Am. Coll. Cardiol., April 14, 2009; 53(15): e1 - e90. [Full Text] [PDF]
|
|
|
|
 |
|
 2005 WRITING COMMITTEE MEMBERS, S. A. Hunt, W. T. Abraham, M. H. Chin, A. M. Feldman, G. S. Francis, T. G. Ganiats, M. Jessup, M. A. Konstam, D. M. Mancini, et al. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart and Lung Transplantation Circulation, April 14, 2009; 119(14): e391 - e479. [Full Text] [PDF]
|
|
|
|
 |
|
 L. A. Allen, J. E. Yager, M. J. Funk, W. C. Levy, J. A. Tulsky, M. T. Bowers, G. C. Dodson, C. M. O'Connor, and G. M. Felker Discordance Between Patient-Predicted and Model-Predicted Life Expectancy Among Ambulatory Patients With Heart Failure JAMA, June 4, 2008; 299(21): 2533 - 2542. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Shanawani, M. D. Wenrich, M. R. Tonelli, and J. R. Curtis Meeting Physicians' Responsibilities in Providing End-of-Life Care Chest, March 1, 2008; 133(3): 775 - 786. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. J. Hauptman Palliation in heart failure: When less and more are more American Journal of Hospice and Palliative Medicine, March 1, 2006; 23(2): 150 - 152. [PDF]
|
|
|
|
|
|
M. P. Davis, N. M. Albert, and J. B. Young Palliation of heart failure American Journal of Hospice and Palliative Medicine, May 1, 2005; 22(3): 211 - 222. [Abstract] [PDF]
|
|
|
|
|
|
D. R. Thompson, A. Roebuck, and S. Stewart Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure Eur J Heart Fail, March 16, 2005; 7(3): 377 - 384. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. J. Hauptman and E. P. Havranek Integrating Palliative Care Into Heart Failure Care Arch Intern Med, February 28, 2005; 165(4): 374 - 378. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Formiga, D. Chivite, C. Ortega, S. Casas, J.M. Ramon, and R. Pujol End-of-life preferences in elderly patients admitted for heart failure QJM, December 1, 2004; 97(12): 803 - 808. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K A Gaber, M Barnett, Y Planchant, and C R McGavin Attitudes of 100 patients with chronic obstructive pulmonary disease to artificial ventilation and cardiopulmonary resuscitation Palliative Medicine, October 1, 2004; 18(7): 626 - 629. [Abstract] [PDF]
|
|
|
|
|
|
S. Z. Pantilat and A. E. Steimle Palliative Care for Patients With Heart Failure JAMA, May 26, 2004; 291(20): 2476 - 2482. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. A. Jackson, J. L. Yarzebski, R. J. Goldberg, B. Wheeler, J. H. Gurwitz, D. M. Lessard, S. E. Bedell, and J. M. Gore Do-Not-Resuscitate Orders in Patients Hospitalized With Acute Myocardial Infarction: The Worcester Heart Attack Study Arch Intern Med, April 12, 2004; 164(7): 776 - 783. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. F. Lewis, S. W. Tsang, J. C. Fang, G. H. Mudge, J. A. Jarcho, C. M. Flavell, A. Nohria, M. M. Givertz, G. S. Couper, J. G. Byrne, et al. Frequency and impact of delayed decisions regarding heart transplantation on long-term outcomes in patients with advanced heart failure J. Am. Coll. Cardiol., March 3, 2004; 43(5): 794 - 802. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Frank, D. K. Heyland, B. Chen, D. Farquhar, K. Myers, and K. Iwaasa Determining resuscitation preferences of elderly inpatients: a review of the literature Can. Med. Assoc. J., October 14, 2003; 169(8): 795 - 799. [Abstract] [Full Text]
|
|
|
|
 |
|
 H. K. Eltzschig, R. Ehlers, S. K. Shernan, W. Rodriguez, S. M. Silver, D. Schoevaerdts, C. Swine, D. Vanpee, M. Jessup, and S. Brozena Heart Failure N. Engl. J. Med., September 4, 2003; 349(10): 1002 - 1004. [Full Text] [PDF]
|
|
|
|
|
|
L. W. Stevenson Clinical Use of Inotropic Therapy for Heart Failure: Looking Backward or Forward?: Part II: Chronic Inotropic Therapy Circulation, July 29, 2003; 108(4): 492 - 497. [Full Text] [PDF]
|
|
|
|
 |
|
 M. Naughton, M. Davis, and C. F. von Gunten Discussing Do-Not-Resuscitate Status: Furthering the Discourse J. Clin. Oncol., May 1, 2003; 21(90090): 26s - 26. [Full Text] [PDF]
|
|
|
|
 |
|
 B. Stuart Transition Management: A New Paradigm for Home Care of the Chronically Ill Near the End of Life Home Health Care Management Practice, February 1, 2003; 15(2): 126 - 135. [Abstract] [PDF]
|
|
|
|
|
|
A. Nohria, E. Lewis, and L. W. Stevenson Medical Management of Advanced Heart Failure JAMA, February 6, 2002; 287(5): 628 - 640. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M.C. Petrie, C. Berry, S. Stewart, and J.J.V. McMurray Failing ageing hearts Eur. Heart J., November 1, 2001; 22(21): 1978 - 1990. [PDF]
|
|
|
|
 |
|
 A Bowling and S Ebrahim Measuring patients' preferences for treatment and perceptions of risk Qual. Saf. Health Care, September 1, 2001; 10(90001): i2 - 8. [Full Text] [PDF]
|
|
|
|
|
|
M. Naughton, M. Davis, and C. F. von Gunten Discussing Do-Not-Resuscitate Status: Furthering the Discourse J. Clin. Oncol., July 1, 2001; 19(13): 3301 - 3302. [Full Text]
|
|
|
|
|
|
P. H. Ditto, J. H. Danks, W. D. Smucker, J. Bookwala, K. M. Coppola, R. Dresser, A. Fagerlin, R. M. Gready, R. M. Houts, L. K. Lockhart, et al. Advance Directives as Acts of Communication: A Randomized Controlled Trial Arch Intern Med, February 12, 2001; 161(3): 421 - 430. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. E. Heffner and C. Barbieri End-of-Life Care Preferences of Patients Enrolled in Cardiovascular Rehabilitation Programs Chest, May 1, 2000; 117(5): 1474 - 1481. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Ebrahim Do not resuscitate decisions: flogging dead horses or a dignified death? BMJ, April 29, 2000; 320(7243): 1155 - 1156. [Full Text]
|
|
|
|
|
|
S. J. Goodlin, Z. Zhong, J. Lynn, J. M. Teno, J. P. Fago, N. Desbiens, A. F. Connors Jr, N. S. Wenger, and R. S. Phillips Factors Associated With Use of Cardiopulmonary Resuscitation in Seriously Ill Hospitalized Adults JAMA, December 22, 1999; 282(24): 2333 - 2339. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. M. DuBois Non-Heart-Beating Organ Donation: A Defense of the Required Determination of Death J. Law Med. Ethics, June 1, 1999; 27(2): 126 - 136. [PDF]
|
|
|
|
 |
|
 Resuscitation Preferences for Heart Failure Patients Journal Watch (General), September 1, 1998; 1998(901): 2 - 2. [Full Text]
|
|
|
|
|
|
L. W. Stevenson Rites and Responsibility for Resuscitation in Heart Failure : Tread Gently on the Thin Places Circulation, August 18, 1998; 98(7): 619 - 622. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||