Abstract 15506: Resuscitation Preferences at the End of Life in Community Patients With Heart Failure
Background: Focus on advance care planning and end of life decision-making in patients with heart failure (HF) has frequently lagged behind other diseases with similar prognoses. We examined the resuscitation preferences and timing and use of palliative medicine and hospice services in a cohort of deceased patients with HF.
Methods: We enrolled consecutive Olmsted County residents presenting with HF from October 2007 through September 2011 into a longitudinal study. Information on resuscitation preference (Full Code or Do-Not-Resuscitate [DNR]), advance directives, and use of palliative medicine and hospice services were obtained from the medical record of patients who died prior to May 1, 2013.
Results: Of the 608 patients enrolled, 237 died during follow-up. Most decedents were elderly (mean age at death 80 years), 54.9% were men, and 49.1% had preserved ejection fraction (EF ≥50%). At enrollment, most patients (n=162, 68.4%) were Full Code, whereas at death, the vast majority (n=186, 78.5%) were DNR. Of 194 patients who had a DNR order documented at some time during follow-up, 47 (24.2%) changed their resuscitation preference back to Full Code at least once after being DNR. The median (25th, 75th percentile) time from a final decision to be DNR until death was only 37 (7, 170) days. Most (84.8%) documented DNR decisions were made in the hospital, while only 15.2% were made in the outpatient setting. Palliative medicine consultations were obtained in 103 (43.5%) patients, but only a median (25th, 75th percentile) of 40 (6, 146) days prior to death. In total, 92 (38.8%) patients were enrolled in hospice a median (25th, 75th percentile) of 30 (6, 68) days prior to death. Adjusting for age and sex, patients with an advance directive were more likely to be DNR (OR 2.51, 95% CI 1.20, 5.24) and more often utilized hospice services (OR 2.17, 95% CI 1.07-4.58) prior to death.
Conclusions: Changes in resuscitation preference are frequently made during an acute hospitalization and within days of death. Palliative medicine consultations and hospice are used in less than half of dying community HF patients, and often during the final days to weeks of life. Further work is needed to better understand the optimal timing and triggers for end of life decision-making in patients with HF.
- © 2013 by American Heart Association, Inc.