Department of Renal Medicine & Transplantation, St Georges Hospital, London, UK
Correspondence and offprint requests to: M. E. Ostermann, Department of Renal Medicine & Transplantation, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK. Email: marlies{at}ostermann.freeserve.co.uk
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Abstract |
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Methods. During outpatient clinic follow-up between January and March 2001, 66 haemodialysis patients were interviewed by one of two interviewers. A standard interview format was used, which included information on complications and outcome of CPR in haemodialysis patients. Patients had no prior opportunity to discuss the issue with a third party.
Results. Fifty patients (76%) wished to receive CPR. Five patients decided against CPR, of whom two were depressed. Six patients were undecided. Five patients were excluded from the analysis because of lack of mental capacity or language difficulties. Patients who wished to receive CPR were significantly younger (59 ± 16 vs 74 ± 10 years, respectively; P < 0.01) and had a significantly higher serum albumin level compared with those who did not opt for CPR or were undecided. There was no difference in gender, comorbidity, length of time on dialysis, proportion of patients with adequate dialysis and mean haemoglobin level between those who wished CPR and those who did not.
Conclusions. The majority of haemodialysis patients wished to receive CPR. These patients were younger than those who did not opt for CPR. Clearer strategies on third-party consultation and follow-up interviews are needed to guarantee that patients wishes are respected at all times.
Keywords: cardiopulmonary resuscitation; haemodialysis patients
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Introduction |
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The attitudes of dialysis patients towards CPR have been studied previously with data available from the USA, Canada, Taiwan and Japan [38], but there is no data from a UK population. None of these studies differentiated between cardiac arrest during dialysis, where resuscitation of a volume deplete patient has a high success rate, and cardiac arrest not related to dialysis, where outcome is much poorer [2].
Our objective was to ascertain the initial attitudes of haemodialysis patients in the UK as to whether they wished to undergo CPR in the event of an in-hospital cardiac arrest not related to dialysis.
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Subjects and methods |
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The patients were then asked whether they would want to receive CPR in the event of a cardiac arrest whilst in hospital but not on dialysis. Patients who after this informed discussion decided not to have CPR were screened for underlying depression using a validated two-question case-finding questionnaire with a sensitivity of 96% [95% confidence interval (CI): 9099%] and a specificity of 57% (95% CI: 5362%) for diagnosing major depression [9,10]: Question 1. During the past month, have you often been bothered by feeling down, depressed or hopeless? Question 2. During the past month, have you often been bothered by having little interest or pleasure in doing things? Patients who answered no to both questions were unlikely to have major depression. Patients who answered yes to either question were screened for more specific symptoms of depression (weight changes, sleep disturbance, psychomotor problems, feelings of guilt, suicidal intentions, depressed mood). Appropriate counselling and treatment were offered to those who fulfilled criteria for depression.
Patients demographic data, comorbidities, previous admissions to an intensive care unit (ICU), status on the transplant waiting list and latest haemoglobin (Hb) and serum albumin level were recorded. Adequacy of dialysis was assessed by the most recent Kt/V value or urea reduction ratio.
Statistical analysis
Patients who decided to have CPR were compared with those who did not wish to have CPR or were undecided, using the Wilcoxon test for continuous variables and Fishers exact test for categorical variables.
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Results |
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Patients who wished to receive CPR were significantly younger and had a significantly higher mean serum albumin level compared with those who decided against CPR or were undecided (Table 1). There was no difference in gender, ethnicity, comorbidity, proportion of patients who had been on dialysis for >2 years and proportion of patients who lived alone. The percentages of patients receiving inadequate dialysis were similar in both groups as was their mean Hb.
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Discussion |
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The most significant factor in deciding not to opt for full CPR or being undecided about it was patient age. This is borne out by those patients interviewed by interviewer 1 alone, where a significant difference in ages between those opting for full CPR and those not was seen. This is likely to reflect perceptions about general life expectancy in patients as they get older and is regardless of their severe chronic illness and reliance on medical technology to sustain life.
Discussions about end-of-life questions touch very sensitive issues and can cause distress. It is not always possible to come to a decision at a single consultation. Sometimes patients need to think about the issue for longer. Also, their choices may not be stable. Danis et al. [11] asked 2536 patients about their desire for life-sustaining treatment if they were to become terminally ill. They repeated the questions 2 years later and concluded that it was important not to assume the stability of patients choices, but to review them regularly. We did not conduct repeat interviews in our patients. Although ascertaining patients views on their CPR status is a continuous ongoing process, there are no data on how often patients preferences should be re-evaluated and where to document these decisions and potential changes in order to guarantee that patients wishes can be respected at all times.
Patients often wish to discuss the issue with a third party (relative, friend, minister/priest). Some patients are reluctant even to think about end-of-life issues without consulting their family and some prefer to leave the decision entirely to their relatives. None of the patients in our group were given prior warning about the discussion nor had they the opportunity to discuss it with anyone. Only two of our patients were accompanied during their clinic visit. This was purely by chance and in neither case was there opportunity to discuss the issue with the accompanying person during the interview.
Language difficulties, a common problem in multicultural societies, can also hamper end-of-life discussions. Although patients who are unable to speak English are often excluded from investigational studies [6,8], in clinical practice independent interpreters should always be available. Family members often act as interpreters, but they might have their own views and may influence the discussion by adding their own emphasis to the questions posed. We had to exclude two of the four patients with language difficulties, because no independent interpreter was available in the hospital at that time.
It is possible that the duration of the relationship between doctor and patient might have an impact on the decision making process. Seniority of physician may also play a role, as shown by Cook et al. [12] who investigated prevalence and procurement patterns of explicit CPR directives for patients admitted to ICU. They found that senior physicians were more likely than residents to establish do-not-resuscitate than resuscitate directives. In our survey, all patients who decided against full CPR were seen by the Consultant. It is possible that in addition to the older age of the patients in this group, patients preferred talking about CPR with somebody whom they had known for longer.
The individual style of the interviewer is another factor that can influence the outcome of the discussion. Tulsky et al. [13] analysed how physicians discuss advance directives with patients and found major differences in style, vocabulary used, explicitness of information, length of interview and physicians own attitudes towards end-of-life discussions. Although a repeat cross-over interview might establish how relevant these interviewer-specific factors are, it introduces bias because patients have time for consideration of the issues between interviews.
End-of-life discussions are particularly sensitive issues in patients with chronic illnesses. Discussing these issues requires the appropriate time and conditions. A busy outpatient clinic does not necessarily provide the best environment. However, within the time constraints of this study we felt it to be the most suitable option. Clinic visit time was extended as required for each individual patient to accommodate the discussion, which lasted 10 min. Patients who do not want to undergo CPR often need additional time and understanding to explore this choice. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) showed that only 48% of patients who did not want CPR had discussed their preferences with their physician [14].
Two patients in our cohort who opted against CPR (aged 81 and 46 years) were subsequently found to be clinically depressed. The former had a recent spouse bereavement and the latter was HIV positive. The incidence of depressive symptoms in a haemodialysis population can be as high as 44% [15]. We only screened for depression in those patients who did not wish full CPR and so cannot estimate the incidence in our cohort as a whole.
Whether our findings also apply to peritoneal dialysis patients is not clear. The literature has conflicting results as to whether there are differences in end-of-life decisions between patients on haemodialysis and peritoneal dialysis [3,4].
Our survey demonstrates the difficulties associated with discussions about CPR, but should also be viewed as a stimulus for further work in this area. Regular follow-up interviews, ideally by only one interviewer, time for discussion with a third party and the provision of independent interpreters for all patients with language difficulties might give a clearer picture on dialysis patients preferences towards CPR.
We concluded that the majority of our haemodialysis patients at initial discussion wanted to undergo CPR. There was a significant difference in age, but not in gender, comorbidity, length of time on dialysis, proportion of patients with adequate dialysis and mean Hb level between patients who wanted CPR and those who did not. Clearer strategies on third party consultation and follow-up interviews are needed to guarantee that patients wishes can be respected at all times.
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Acknowledgments |
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Conflict of interest statement. None declared.
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References |
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