Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

doi:10.1016/j.jpainsymman.2022.03.009

. 2022 Jun;63(6):e621-e632.

doi: 10.1016/j.jpainsymman.2022.03.009.

Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

Renee D Stapleton¹, Dee W Ford², Katherine R Sterba³, Nandita R Nadig⁴, Steven Ades⁵, Anthony L Back⁶, Shannon S Carson⁷, Katharine L Cheung⁸, Janet Ely⁹, Erin K Kross¹⁰, Robert C Macauley¹¹, Jennifer M Maguire¹², Theodore W Marcy¹³, Jennifer J McEntee¹⁴, Prema R Menon¹⁵, Amanda Overstreet¹⁶, Christine S Ritchie¹⁷, Blair Wendlandt¹⁸, Sara S Ardren¹⁹, Michael Balassone²⁰, Stephanie Burns²¹, Summer Choudhury²², Sandra Diehl²³, Ellen McCown²⁴, Elizabeth L Nielsen²⁵, Sudiptho R Paul²⁶, Colleen Rice²⁶, Katherine K Taylor²⁷, Ruth A Engelberg²⁸

Affiliations

¹ Pulmonary and Critical Medicine, HSRF 222 (R.D.S), University of Vermont Larner College of Medicine, Burlington, Vermont, USA. Electronic address: renee.stapleton@med.uvm.edu.
² Division Director and Professor, Pulmonary, Critical Care, and Sleep Medicine, CSB 816, MSC 630 (D.W.F.), Medical University of South Carolina, Charleston, South Carolina, USA.
³ Public Health Sciences (K.R.S.), Medical University of South Carolina, Charleston, South Carolina, USA.
⁴ Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine (N.R.N.), Chicago, Illinois, USA.
⁵ Hematology and Oncology (S.A.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
⁶ Department of Medicine (A.L.B.), University of Washington, Seattle, Washington, USA.
⁷ Pulmonary and Critical Care Medicine (S.S.C.), University of North Carolina, Chapel Hill, North Carolina, USA.
⁸ Nephrology (K.L.C.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
⁹ University of Vermont Cancer Center (J.E.), Burlington, Vermont, USA.
¹⁰ Division of Pulmonary, Critical Care & Sleep Medicine, Co-Director of Cambia Palliative Care Center of Excellence at UW Medicine (E.K.K.), University of Washington, Seattle, Washington, USA.
¹¹ Oregon Health Sciences University (R.C.M.), Portland, Oregon, USA.
¹² Pulmonary and Critical Care Medicine (J.M.M.), University of North Carolina, Chapel Hill, North Carolina, USA.
¹³ Pulmonary and Critical Care Medicine (T.W.M.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
¹⁴ Internal Medicine and Pediatrics, Palliative Care and Hospice Medicine (J.J.M.), University of North Carolina, Chapel Hill, North Carolina, USA.
¹⁵ Vertex Pharmaceuticals (P.R.M.), Boston, Massachusetts, USA.
¹⁶ Geriatrics and Palliative Care (A.O.), Medical University of South Carolina, Charleston, SC.
¹⁷ Harvard Medical School (C.S.R.), Boston, Massachusetts, USA.
¹⁸ Pulmonary and Critical Care Medicine (B.W.), University of North Carolina, Chapel Hill, North Carolina, USA.
¹⁹ University of Vermont Larner College of Medicine (S.S.A.), Burlington, Vermont, USA.
²⁰ Division of Pulmonary and Critical Care Medicine (M.B.), Medical University of South Carolina, Charleston, South Carolina, USA.
²¹ University of Vermont Larner College of Medicine (S.B.), Burlington, Vermont, USA.
²² North Carolina Translational and Clinical Sciences Institute (S.C.), University of North Carolina, Chapel Hill, North Carolina, USA.
²³ University of Vermont Medical Center (S.D.), Burlington, Vermont, USA.
²⁴ Spiritual Care (E.M.), University of Washington Medical Center, Seattle, Washington, USA.
²⁵ Cambia Palliative Care Center of Excellence at UW Medicine (E.L.N), University of Washington, Seattle, Washington, USA.
²⁶ Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA.
²⁷ Pulmonary, Critical Care, and Sleep Medicine (K.K.T), Medical University of South Carolina, Charleston, South Carolina, USA.
²⁸ Pulmonary, Critical Care & Sleep Medicine, Cambia Palliative Care Center of Excellence at UW Medicine (R.A.E.), University of Washington, Seattle, Seattle, Washington, USA.

PMID: 35595375
PMCID: PMC9179950
DOI: 10.1016/j.jpainsymman.2022.03.009

Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

Renee D Stapleton et al. J Pain Symptom Manage. 2022 Jun.

. 2022 Jun;63(6):e621-e632.

doi: 10.1016/j.jpainsymman.2022.03.009.

Authors

Affiliations

¹ Pulmonary and Critical Medicine, HSRF 222 (R.D.S), University of Vermont Larner College of Medicine, Burlington, Vermont, USA. Electronic address: renee.stapleton@med.uvm.edu.
² Division Director and Professor, Pulmonary, Critical Care, and Sleep Medicine, CSB 816, MSC 630 (D.W.F.), Medical University of South Carolina, Charleston, South Carolina, USA.
³ Public Health Sciences (K.R.S.), Medical University of South Carolina, Charleston, South Carolina, USA.
⁴ Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine (N.R.N.), Chicago, Illinois, USA.
⁵ Hematology and Oncology (S.A.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
⁶ Department of Medicine (A.L.B.), University of Washington, Seattle, Washington, USA.
⁷ Pulmonary and Critical Care Medicine (S.S.C.), University of North Carolina, Chapel Hill, North Carolina, USA.
⁸ Nephrology (K.L.C.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
⁹ University of Vermont Cancer Center (J.E.), Burlington, Vermont, USA.
¹⁰ Division of Pulmonary, Critical Care & Sleep Medicine, Co-Director of Cambia Palliative Care Center of Excellence at UW Medicine (E.K.K.), University of Washington, Seattle, Washington, USA.
¹¹ Oregon Health Sciences University (R.C.M.), Portland, Oregon, USA.
¹² Pulmonary and Critical Care Medicine (J.M.M.), University of North Carolina, Chapel Hill, North Carolina, USA.
¹³ Pulmonary and Critical Care Medicine (T.W.M.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
¹⁴ Internal Medicine and Pediatrics, Palliative Care and Hospice Medicine (J.J.M.), University of North Carolina, Chapel Hill, North Carolina, USA.
¹⁵ Vertex Pharmaceuticals (P.R.M.), Boston, Massachusetts, USA.
¹⁶ Geriatrics and Palliative Care (A.O.), Medical University of South Carolina, Charleston, SC.
¹⁷ Harvard Medical School (C.S.R.), Boston, Massachusetts, USA.
¹⁸ Pulmonary and Critical Care Medicine (B.W.), University of North Carolina, Chapel Hill, North Carolina, USA.
¹⁹ University of Vermont Larner College of Medicine (S.S.A.), Burlington, Vermont, USA.
²⁰ Division of Pulmonary and Critical Care Medicine (M.B.), Medical University of South Carolina, Charleston, South Carolina, USA.
²¹ University of Vermont Larner College of Medicine (S.B.), Burlington, Vermont, USA.
²² North Carolina Translational and Clinical Sciences Institute (S.C.), University of North Carolina, Chapel Hill, North Carolina, USA.
²³ University of Vermont Medical Center (S.D.), Burlington, Vermont, USA.
²⁴ Spiritual Care (E.M.), University of Washington Medical Center, Seattle, Washington, USA.
²⁵ Cambia Palliative Care Center of Excellence at UW Medicine (E.L.N), University of Washington, Seattle, Washington, USA.
²⁶ Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA.
²⁷ Pulmonary, Critical Care, and Sleep Medicine (K.K.T), Medical University of South Carolina, Charleston, South Carolina, USA.
²⁸ Pulmonary, Critical Care & Sleep Medicine, Cambia Palliative Care Center of Excellence at UW Medicine (R.A.E.), University of Washington, Seattle, Seattle, Washington, USA.

PMID: 35595375
PMCID: PMC9179950
DOI: 10.1016/j.jpainsymman.2022.03.009

Abstract

Context: Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree.

Objectives: Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families.

Methods: This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness.

Results: Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending.

Conclusions: IA is a feasible and reasonable approach to CPR discussions in selected patient populations.

Keywords: Code status; cardiopulmonary resuscitation; communication; end-of-life; seriously ill patients.

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Figures

**Figure 1:**
Informed Assent Discussion Guide/Checklist

See this image and copyright information in PMC

References

1. https://www.heart.org/en/professional/quality-improvement/get-with-the-g..., accessed Dec. 27, 2021.
1. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009;361:22–31. - PMC - PubMed
1. Stapleton RD, Ehlenbach WJ, Deyo RA, Curtis JR. Long-term outcomes after in-hospital cardiopulmonary resuscitation in older adults with chronic illness. Chest 2014. - PMC - PubMed
1. Schluep M, Gravesteijn BY, Stolker RJ, Endeman H, Hoeks SE. One-year survival after in-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 2018;132:90–100. - PubMed
1. Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med 2007;357:1340–4. - PubMed

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[1] https://www.heart.org/en/professional/quality-improvement/get-with-the-g..., accessed Dec. 27, 2021.

[2] https://www.heart.org/en/professional/quality-improvement/get-with-the-g..., accessed Dec. 27, 2021.

[3] Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009;361:22–31. - PMC - PubMed

[4] Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009;361:22–31. - PMC - PubMed

[5] Stapleton RD, Ehlenbach WJ, Deyo RA, Curtis JR. Long-term outcomes after in-hospital cardiopulmonary resuscitation in older adults with chronic illness. Chest 2014. - PMC - PubMed

[6] Stapleton RD, Ehlenbach WJ, Deyo RA, Curtis JR. Long-term outcomes after in-hospital cardiopulmonary resuscitation in older adults with chronic illness. Chest 2014. - PMC - PubMed

[7] Schluep M, Gravesteijn BY, Stolker RJ, Endeman H, Hoeks SE. One-year survival after in-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 2018;132:90–100. - PubMed

[8] Schluep M, Gravesteijn BY, Stolker RJ, Endeman H, Hoeks SE. One-year survival after in-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 2018;132:90–100. - PubMed

[9] Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med 2007;357:1340–4. - PubMed

[10] Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med 2007;357:1340–4. - PubMed

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Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

Affiliations

Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

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