Haemodialysis patients’ views on their resuscitation status

Maria E. Ostermann and Stephen R. Nelson

Department of Renal Medicine & Transplantation, St George’s Hospital, London, UK

Correspondence and offprint requests to: M. E. Ostermann, Department of Renal Medicine & Transplantation, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK. Email: marlies{at}ostermann.freeserve.co.uk



   Abstract
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Background. Guidelines on cardiopulmonary resuscitation (CPR) recommend that decisions about resuscitation are part of every patient’s care plan. We aimed to ascertain the initial views of a haemodialysis cohort in the UK regarding their CPR status in the event of an in-hospital cardiac arrest not related to dialysis.

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



   Introduction
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Patients are increasingly involved in discussions about their care, especially with respect to the initiation of life-sustaining therapies, like renal replacement, mechanical ventilation or end-of-life issues, and decisions on cardiopulmonary resuscitation (CPR) should be part of every patient’s care plan [1]. Dialysis patients represent a particular patient population whose life depends on long-term complex medical technology, but in whom CPR rarely results in extended survival [2].

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.



   Subjects and methods
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
During a 3 month period from January to March 2001, 66 consecutive outpatient haemodialysis patients were interviewed during routine clinic visits by one of two interviewers (interviewer 1, Consultant Nephrologist; interviewer 2, Senior Trainee in Nephrology). Hospital in-patients and those with acute medical problems were excluded. An agreed standard format for the discussions was used by both interviewers. In the first instance, the difference in causes and outcomes between collapse on and off dialysis was explained to the patient. They were made aware that a collapse whilst on dialysis was likely to be related to their circulating volume status, which could be remedied. Patients were advised that data on outcome of CPR in dialysis patients whilst off dialysis was limited, but one study had shown that <10% of dialysis patients undergoing CPR had survived to hospital discharge with only 3% still alive 6 months later [2]. In addition, patients were informed about potential complications related to CPR, brain injury being the most serious one. The technique of CPR was described. In the event that a patient lacked capacity (unable to understand the information, retain it or make a balanced judgement), this was recorded as such. For patients with language difficulties (n = 4), attempts were made to have an independent interpreter present.

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): 90–99%] and a specificity of 57% (95% CI: 53–62%) 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 Fisher’s exact test for categorical variables.



   Results
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Sixty-six consecutive stable haemodialysis patients from a total haemodialysis population of 109 patients were interviewed. Five patients were excluded from the final analysis: three patients lacked mental capacity and two patients had significant language difficulties and no interpreter was available. Of 61 patients, 50 patients wished to have CPR in the event of an in-hospital cardiac arrest. Five patients made an informed decision against CPR, of whom two patients fulfilled the criteria for depression and were offered counselling and treatment. Six patients were undecided: two preferred to leave the decision to the medical staff, two expressed their wish not to be resuscitated to a poor quality of life and two patients did not want to think about the issue.

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.


View this table:
[in this window]
[in a new window]
 
Table 1. Baseline demographic data on patients

 
All 11 patients who opted against CPR or were undecided were interviewed by interviewer 1 (Con-sultant Nephrologist). However, the mean age of all patients seen by interviewer 1 was significantly higher than those seen by interviewer 2 (64 ± 15 vs 55 ± 15 years, respectively; P = 0.03). Of the 43 patients seen by interviewer 1, the mean age of the 32 patients who wished to have CPR was significantly lower than that of the 11 patients who did not wish CPR or were undecided about it (60 ± 16 vs 74 ± 10 years, respectively; P < 0.002).



   Discussion
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Our survey showed that at initial discussion, the majority (76%) of haemodialysis patients wished to undergo CPR in the event of an in-hospital cardiac arrest. These decisions were not affected by significant comorbidities, previous experience in the ICU or having had dialysis for several years and are consistent with data from other countries [38].

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.



   Acknowledgments
 
We would like to thank Nandita De Souza for her expert help with this manuscript.

Conflict of interest statement. None declared.



   References
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 

  1. British Medical Association, Resuscitation Council (UK) and Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation; a joint statement 2001. BMA website (www.bma.org.uk)
  2. Moss AH, Holley JL, Upton MB. Outcomes of cardiopulmonary resuscitation in dialysis patients. J Am Soc Nephrol 1992; 3: 1238–1243[Abstract]
  3. Holley JL, Finucane TE, Moss AH. Dialysis patients’ attitudes about cardiopulmonary resuscitation and stopping dialysis. Am J Nephrol 1989; 9: 245–251[ISI][Medline]
  4. Quintana BJ, Nevarez M, Rogers K, Murata GH, Tzamaloukas AH. Reaction of patients on chronic dialysis to discussions about cardiopulmonary resuscitation. ANNA J 1991; 18: 29–32[Medline]
  5. Miura Y, Asai A, Nagata S et al. Dialysis patients’ preferences regarding cardiopulmonary resuscitation and withdrawal of dialysis in Japan. Am J Kidney Dis 2001; 37: 1216–1222[ISI][Medline]
  6. Singer PA, Thiel EC, Naylor CD et al. Life-sustaining treatment preferences of hemodialysis patients: implications for advance directives. J Am Soc Nephrol 1995; 6: 1410–1417[Abstract]
  7. Moss AH, Hozayen O, King K, Holley JL, Schmidt RJ. Attitudes of patients toward cardiopulmonary resuscitation in the dialysis unit. Am J Kidney Dis 2001; 38: 847–852[ISI][Medline]
  8. Tzamaloukas AH, Zager PG, Quintana BJ, Nevarez M, Rogers K, Murata GH. Mechanical cardiopulmonary resuscitation choice of patients on chronic peritoneal dialysis. Perit Dial Int 1990; 10: 299–302[ISI][Medline]
  9. Whooley MA, Simon GE. Managing depression in medical outpatients. N Engl J Med 2000; 343: 1942–1950[Free Full Text]
  10. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997; 12: 439–445[CrossRef][ISI][Medline]
  11. Danis M, Garrett J, Harris R, Patrick DL. Stability of choices about life-sustaining treatments. Ann Intern Med 1994; 120: 567–573[Abstract/Free Full Text]
  12. Cook DJ, Guyatt G, Rocker G et al. for the Canadian Critical Care Trials Group. Cardiopulmonary resuscitation directives on admission to intensive care unit: an international observational study. Lancet 2001; 358: 1941–1945[CrossRef][ISI][Medline]
  13. Tulsky JA, Fischer GA, Rose MR, Arnold RM. Opening the black box: how do physicians communicate about advance directives? Ann Intern Med 1998; 129: 441–449[Abstract/Free Full Text]
  14. Phillips RS, Wenger NS, Teno J et al. Choices of seriously ill patients about cardiopulmonary resuscitation: correlates and outcomes. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Am J Med 1996; 100: 128–137[CrossRef][ISI][Medline]
  15. Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis 2003; 41: 105–110[CrossRef][ISI][Medline]
Received for publication: 6.12.01
Accepted in revised form: 26. 3.03





This Article
Abstract
FREE Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Ostermann, M. E.
Articles by Nelson, S. R.
PubMed
PubMed Citation
Articles by Ostermann, M. E.
Articles by Nelson, S. R.