Dec 012017
 

Physicians and patients alike tend to avoid frank discussions about “code status” -- whether a patient would want CPR or mechanical ventilation in the event of a cardiac or respiratory arrest. When doctors address code status at all, they tend to phrase the questions in such a way to cut off any thoughtful discussion: “If your heart stops, do you want us to restart it?” “If you stop breathing, do you want to go on a ventilator?” The answers to these questions are almost always yes, and the conversation is a short one.

This perfunctory approach leaves unchallenged the often unrealistic beliefs most people bring to the hospital regarding CPR and mechanical ventilation. In movies and TV shows, actors emerge from CPR not just alive, but beautiful.

In reality, only a minority of people experiencing cardiac arrest during a hospitalization survive to hospital discharge. When a patient experiences a PEA/asystole arrest in the ICU while on vasopressors, their likelihood of survival to hospital discharge falls below 10%, and survival with good neurologic function a dismal 2%. (Patients experiencing shockable ventricular tachycardia or fibrillation due to acute cardiac ischemia tend to do better.)

Several studies have found that when patients are shown videos depicting real or simulated CPR and mechanical ventilation, they choose a do-not-resuscitate status more often:

  • Among 119 patients (mostly elderly men) hospitalized on a general medicine unit at a Veterans Affairs hospital in Minnesota, the half who watched a 6-minute video depicting simulated CPR and intubation chose a do-not-resuscitate and do-not-intubate status (DNR/DNI) 56% of the time, compared to 17% of those who simply discussed code status with their care team. Only 37% chose “full-code” status after watching the video, compared to 71% with discussion only.
  • Patients with advanced cancer who watched a video of CPR and mechanical ventilation chose DNR 79% of the time, compared to 51% of patients who only heard a narrative about code status options.
  • Elderly patients with severe heart failure who viewed a video selected “comfort care” half the time (vs. 30% among patients hearing verbal explanations). They also scored more highly on tests of knowledge about CPR.

Videos have numerous advantages over fallible physician-counselors: they are standardized, unemotional, endlessly patient, and available on demand. That’s not to say videos are unbiased: choices in the script, narration, production, and acting in a video could contain hidden but powerful influencing factors.

Why isn’t video explaining CPR and mechanical ventilation standard care in U.S. hospitals? The likely answers are tradition and risk. A hospital deploying video counseling would immediately stand out from its peers, and would most likely have more patients choose DNR, opening itself to political or religious controversy as the “death panel hospital.” Families of patients choosing DNR upset by their loved one’s decision could later sue the hospital for wrongful death (alleging Mom or Dad’s lack of decision making capacity or undue emotional influence by the video).

For that matter, is it appropriate to ask patients or their families to make code status decisions after watching a video? Are hospitalized patients “qualified” and able to interpret what they are seeing? CPR and intubation look brutal, and can be, but those who undergo them are usually unconscious and (we hope) not suffering. Outcomes vary widely, and are unpredictable. Video, especially of simulations, cannot portray these nuances.

Patients’ preferences can and do change, through the course of an illness and over years. But DNR status today is viewed by most medical professionals as an all-or-nothing point of no return, and its revocation is cast as some failure of will. Rightly or not, many people (in health care and out) believe that DNR patients tend to receive less attention and care than “full code” patients. More patients choosing DNR would have unforeseen consequences, for both good and ill.

A meta-analysis of 10 randomized trials testing video counseling around advance care planning reflects this uncertainty. There were no “real world” deployments of video advance care planning. Although patients watching videos chose DNR roughly twice as often, and were generally better informed, there was no way to confirm they were choosing their “true” preferences.

All this makes it worthy of an NPR piece when prominent physicians actually promote the use of videos for advance care planning, drawing national attention even when limited to patients with incurable, terminal cancer. Such videos are available for free download to all health care providers in Hawaii, where the social experiment so far sounds well-received.

Almost no one wants to talk about death -- especially their own. Counseling severely ill patients and their families thrusts physicians into the role of pastor and psychologist, where (not surprisingly) they may flounder or fail. A video can’t replace advance care discussions between physicians, patients and families. But given the human frailty of doctors and patients, the unpredictability of illness, and the mystery of death, everyone might find it a relief to be able to press ‘play,’ at least to start the conversation.

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Should patients watch videos of CPR before code status decisions?