The effect of hospital admission on the opinions and knowledge of elderly patients regarding cardiopulmonary resuscitation

Age and Ageing, Nov, 1997 by Daniel R. Watson, Tim J. Wilkinson, Richard Sainsbury, Julie E. Kidd

Introduction

Asking a patient shortly after admission to hospital whether they would like to be resuscitated in the event of a cardiac arrest may be difficult for the doctor because of concern about provoking anxiety in the patient [1, 2]. It is tempting to delay such conversations until the patient's health has improved. Unfortunately, it is at the beginning of a patient's hospital stay that resuscitation may be more likely to be necessary. Although the wishes of the patient may not have been considered in the past [3], it has become increasingly apparent that patients should be involved in these decisions [4]. `Living wills' may be of use to physicians, patients and family [5], however they are rarely used in the UK or USA and are not currently recognized in New Zealand law [6].

Elderly people may have different views on whether they would want cardiopulmonary resuscitation (CPR), should it become necessary. We were uncertain to what degree elderly people wished to be consulted about this. We were also unsure how much a person's views might change with time or as their health changed, and hypothesized that their view after recovery from an illness or treatment in hospital may differ from that shortly after hospital admission. Whilst many studies have sought patients' opinions about CPR [7-13], none has compared all patients' opinions at admission and again at discharge from hospital or following a period in hospital.

This study aimed to assess elderly people's opinions and knowledge of CPR, how much they wished to be involved in decision-making and whether their opinions changed during a hospital admission.

Methods

All elderly patients admitted over a 5-week period to all five assessment, treatment and rehabilitation wards at the Princess Margaret Hospital, Christchurch, New Zealand, were eligible to participate in this study. The unit admits approximately 2000 patients per year, which equates to around 15 patients/bed/year. Fifty-five percent of patients are admitted directly from the community and 45% are transferred from other hospitals. The median length of stay is 18 days. The number of CPR calls averages four per month.

Patients were excluded if they had communication difficulties, dementia -- as evidenced by a Mini-Mental State Examination score [14] of 20 or less, acute confusion, depression or if they could not otherwise give informed consent. In addition, patients with a terminal illness such as advanced-stage heart failure, obstructive airways disease or malignancy were not approached for an interview.

Patients read an information sheet that gave an explanation of the nature of and reasons for the study. In order to obtain informed consent, this sheet also provided information about CPR. Specifically, this included how chest compressions and artificial respiration are administered, the possibility that permanent physical or mental handicap may be a complication and why CPR might be needed. Following consent, this information was reinforced and was supplemented orally by information on defibrillation, ventilation and drug administration. The difference between GPR and other life-saving treatments (for example dialysis or antibiotics for pneumonia) was emphasized. They were then asked whether they had heard of CPR before, what it involved and when it might be needed, as well as how effective they believed it to be. Level of knowledge and whether prompting was required for a correct answer were recorded. The success rate of survival to hospital discharge following CPR was then quoted to each participant as being approximately 10% [15]. Any other inaccuracies in patient knowledge were corrected by the interviewer (D.W.). Participants were then asked the following open-ended questions using a semi-structured questionnaire:

1. Would they want CPR performed if it were required?

2. Who should decide whether to perform CPR? (Examples of themselves, their relatives or a doctor were given as possible options.)

3. Could they imagine being in a condition where they would not want CPR and what condition would that be?

4. Were they comfortable with the interview?

5. Did they have objections to another interview prior to discharge?

6. Would they like their wishes recorded in their medical record?

7. Would they like their general practitioner notified of their opinions?

People not wanting CPR were asked if they would want other life-saving measures (for example, antibiotics for pneumonia). It was emphasized that they were participating in a research project and that the results would not affect their care in any way. Their opinion was recorded in the hospital notes, if they wished. The participant's age, sex, marital status, religion and usual type of domicile were recorded. Participants who agreed were interviewed a second time at the time of discharge.

Categorical variables were compared using the [chi square] test. Age was compared between groups using Student's unpaired t-test. Step-wise logistic regression was used to determine which factors were independent predictors of patient preference. Results are given as means with 95% confidence intervals in parentheses (NS = not significant). The study was approved by the Southern Regional Health Authority (Canterbury) ethics committee.