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Randomized Controlled Trial
. 2019 Oct;58(4):567-577.e1.
doi: 10.1016/j.jpainsymman.2019.06.011. Epub 2019 Jun 19.

Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults

Matthew E Modes  1 , Ruth A Engelberg  2 , Lois Downey  2 , Elizabeth L Nielsen  2 , Robert Y Lee  2 , J Randall Curtis  3 , Erin K Kross  2
Affiliations
Randomized Controlled Trial

Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults

Matthew E Modes et al. J Pain Symptom Manage. 2019 Oct.

Abstract

Context: Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values.

Objectives: To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent.

Methods: Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states.

Results: Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804).

Conclusion: Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.

Keywords: Goals-of-care; advance care planning (ACP); cardiopulmonary resuscitation (CPR); end-of-life; palliative care; preferences; values.

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Conflict of interest statement

CONFLICTS OF INTEREST

There are no conflicts of interest from any of the authors.

Matthew E. Modes, MD, MPP = no conflicts of interest

Ruth A. Engelberg, PhD = no conflicts of interest

Lois Downey, MA = no conflicts of interest

Elizabeth L. Nielsen, MPH = no conflicts of interest

Robert Y. Lee, MD = no conflicts of interest

J. Randall Curtis, MD, MPH = no conflicts of interest

Erin K. Kross, MD = no conflicts of interest

Figures

Figure.
Figure.
Patient CPR preference in current health and if dependent on others, by prioritized end-of-life valuea a The sample includes 518 patients with responses to all three questions.
See this image and copyright information in PMC

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