Transcript Are You Smarter Than a 5th Grader?

Are You Smarter
Than an Intern?
CPR Efficacy and Outcomes
Brought to you by:
Shaida Talebreza Brandon M.D.
Assistant Professor, Division of Geriatrics,
University of Utah School of Medicine
Physician Investigator, VA SLC GRECC
Medical Director, Haven HealthCare
Objectives
Describe
the % survival to hospital discharge
after CPR for a variety of clinical situations
List
at least 3 phrases to avoid and alternative
phrases to use when discussing code status
with frail older adults
Conduct
an effective goals of care discussion
regarding code status
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Are You Smarter Than a
Medical Intern?
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Intern Topic 9
Intern Topic 10
4th Year Topic 7
4th Year Topic 8
3rd Year Topic 5
3rd Year Topic 6
2nd Year Topic 3
2nd Year Topic 4
1st Year Topic 1
1st Year Topic 2
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1st Year Topic 1 Question
Knowing
the efficacy of CPR will affect
older patients’ (over 65) decisions about
whether or not they would want it
A.
True
B. False
1st Year Topic 1 Answer
True
Most
older adults not want to undergo
CPR once a clinician explains the
probability of survival after the procedure
Murphy et al. The influence of the probability of survival on patient’s preferences regarding cardiopulmonary
resuscitation. NEnglJMed1994;330:545-549
What Should be Included in Discussions
Before
learning the probability of survival 41% of
patients wanted CPR
After
learning the probability of survival only 22% of
patients wanted CPR
If
asked about CPR wishes in the setting of a lifelimiting illness, in which overall life expectancy was
less than one year, only 5% wanted CPR after
knowing accurate information about CPR outcomes
Murphy et al. The influence of the probability of survival on patient’s preferences regarding cardiopulmonary
resuscitation. NEnglJMed1994;330:545-549
1st Year Topic 2 Question
What
% of all adult CPR patients survive 20
minutes after inpatient CPR according to
the largest and most comprehensive source
of in-hospital CPR outcomes data?
A.
7%
B. 17%
C. 34%
D. 44%
1st Year Topic 2 Answer
44% of patients survived
20 minutes after inpatient CPR
Peberdy MA, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests
from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308.
2nd Year Topic 3 Question
What
% of all inpatient adult CPR patients
survive to hospital discharge according to
the largest and most comprehensive source
of in-hospital CPR outcomes data?
A.
7%
B. 17%
C. 27%
D. 37%
2nd Year Topic 3 Answer
17% of patients survived
to hospital discharge after inpatient CPR
Peberdy, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from
the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308.
Saket, et al. Trends in Survival after In-Hospital Cardiac Arrest N Engl J Med 2012; 367:1912-1920
Efficacy of CPR Cancer and Renal
Dialysis
Cancer:
 Meta-analysis 42 studies from 1966-2005
Since
1990: Localized disease 9.1% and metastatic disease
7.8% of cancer patients survived CPR to discharge
Renal
Dialysis:
3 studies in a total of 137 dialysis patients.
14% of patients survived to discharge
Reisfield GM, et al. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006;
71:152-160.
Hijazi F, Holley JL. Cardiopulmonary resuscitation and dialysis: outcome and patients' views. Seminars in Dialysis. 2003; 16(1):51-53.
2nd Year Topic 4 Question
What
percent of sudden cardiac arrests
happen outside of the hospital?
A.
<50%
B. 50-59%
C. 60-69%
D. 70-79%
E. >80%
2nd Year Topic 4 Answer
More
than 80% of sudden cardiac
arrests happen outside of the hospital1
Less than 10% of these patients
survive to hospital discharge2,3
1. Chugh SS, Jui J, Gunson K, et al. Current burden of sudden cardiac death: multiple source surveillance versus retrospective death
certificate-based review in a large U.S. community. J Am Coll Cardiol 2004;44:1268-75.
2. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA
2008;300:1423-31. [Erratum, JAMA 2008;300:1763.]
3. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics — 2013 update: a report from the American Heart
Association. Circulation 2013;127(1):e6-e245. [Erratum, Circulation 2013;127(1).]
Efficacy of CPR in Older Adults
 Out-of-hospital
cardiac arrest due to a cardiac cause
survival to hospital discharge:
 19.4% of younger patients
 9.4% of octogenarians
 4.4% of nonagenarians
 Age
was a much weaker predictor of survival than other
factors such as initial cardiac rhythm
 Decisions
regarding resuscitation should not be based on
age alone
Kim C, Becker L, Eisenberg M. Out-of-Hospital Cardiac Arrest in Octogenarians and Nonagenarians. Arch Intern Med.
2000;160(22):3439-3443.
3rd Year Topic 5 Question
Which
2 Cardiac Rhythms have better CPR
survival outcomes?
A. PEA, V-fib
B. V-Fib, Asystole
C. Pulseless V-tach,
D. Asystole, PEA
V-fib
Peberdy MA, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the
National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308.
3rd Year Topic 5 Answer
Which
2 Cardiac Rhythms have better
survival outcomes?
Cardiac
rhythm:
V-Fib
Pulseless
V-tach
PEA
Asystole
%
Survivors
34%
35%
10%
10%
Peberdy MA, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the
National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308.
3rd Year Topic 6 Question
What
percentage of CPR survivors over
the age of 65 (in hospital arrest) were
discharged home (i.e. not to hospice or
an in-patient facility) ?
A. 4.8%
B. 40%
C. 55.3%
Chan, et al. Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest. N Engl J Med 2013;368:101926
3rd Year Topic 6 Answer
What
percentage of CPR survivors over
the age of 65 (in hospital arrest) were
discharged home?
Location
Home
Inpatient
Facility*
Hospice in
any Setting
Post CPR:
40%
55.3%
4.8%
Chan, et al. Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest. N Engl J Med 2013;368:101926
3rd Year Topic 6 Answer
If
remaining home is an important patient
goal – consider this:
Location
Home
Inpatient
Facility*
Hospice in
any Setting
Pre-CPR
84%
14.8%
0.2%
Post-CPR
51%
47%
2%
Peberdy MA, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the National Registry of
Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308.
4th Year Topic 7 Question
What
percentage of CPR survivors
over the age of 65 (inpatient arrest) had
mild or no neurological disability at
discharge?
A.
38%
B. 48%
C. 58%
D. 68%
4th Year Topic 7 Answer
48%
of survivors had mild or no neurologic
disability
The rest had moderate-to-severe disability or
were in a coma or vegetative state
Patients with substantial neurologic disability
at discharge were more likely to be
readmitted
Chan, et al. Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest. N Engl J Med 2013;368:1019-26
1-year survival after in-hospital
cardiac arrest for older adults
65
to 74 years: 63.7%
75 to 84 years: 58.6%
85 years or older: 49.7%
Chan, et al. Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest. N Engl J Med 2013;368:1019-26
4th Year Topic 8 Question
Which
5 factors are associated with failure to
survive to discharge after CPR?
 A.
Myocardial Infarction
 B. Dependent status
 C. Hypertension
 D. Dementia
 E.
Sepsis the day prior
to the CPR event
 F. Serum creatinine
>1.5 mg/dl
 G. Metastatic cancer
 H. Coronary Heart
Disease
Ebell MH, et al. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis. J Gen Int Med. 1998; 13(12):805-16.
4th Year Topic 8 Answer
Which
5 factors are associated with failure to
survive to discharge after CPR?
 Sepsis
the day prior to the CPR event
 Serum creatinine >1.5 mg/dl
 Metastatic cancer
 Dementia
 Dependent Status
Ebell MH, et al. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis. J Gen Int Med. 1998; 13(12):805-16.
Intern Topic 9 Question
of CPR on TV – What % of patients
survived to hospital discharge?
Efficacy
Chicago
Hope, ER, Rescue 911 during 19941995 season
Identified
all occurrences of CPR in each
episode and outcomes
60
occurrences of CPR in 97 episodes
Diem SJ, Lantos JA, Tulsky JA. Cardiopulmonary Resuscitation on Television - Miracles and Misinformation.
NEnglJMed1996;334:1578-1582
Intern Topic 9 Question
of CPR on TV – What % of
patients survived to hospital discharge?
Efficacy
A.
67%
B. 77%
C. 87%
D. 97%
Intern Topic 9 Answer
67% of patients survived to hospital
discharge on TV
Diem SJ, Lantos JA, Tulsky JA. Cardiopulmonary Resuscitation on Television - Miracles and Misinformation.
NEnglJMed1996;334:1578-1582
Intern Topic 10 Question
List
two more recommended element of
a code status discussion:
Introduction
Explain
nature, risks, and outcomes of
CPR
Other recommended elements….
Close the conversation
Recommended Elements of a
Code Status Discussion:
 Introduction
 Investigate
patients’ goals, values, expectations
 Ensure patient understands their prognosis
 Explain nature, risks, and outcomes of CPR
 Make a recommendation re CPR consistent with patient’s
prognosis and goals of care
 Close Conversation
Anderson WG, et al. Code Status Discussions Between Attending Hospitalist Physicians and Medical
Patients at Hospital Admission. J Gen Intern Med. 2011 April; 26(4): 359–366
A little more about:
Goals, Values, Expectations

Seek to understand the rational for preferences
rather than just focusing on decisions regarding
interventions




What is important to the patient?
What makes the patient’s life worth living?
Where do they prefer to receive care (home, SNF, etc.)?
Are there circumstances they would consider worse than
death (not being able to recognize family, etc.)?
Your Conversation Starter Kit. Retrieved January 3,2013, from http://theconversationproject.org/starter-kit/intro/
Million Dollar Question
After these brief messages….
Goals of Care Discussions
Goals of Care Discussion Definition
Organized
process of communication to
help an individual understand and discuss
goals, values, and beliefs for future
healthcare decisions based on clinical
circumstances and medical possibilities
Respecting Choices Advance Care Planning Program
Goals of Care Discussion Definition
Ensure
that:
The
health care provider understands the
patient’s goals, values, and beliefs
The
patient understands the implications
of their decisions regarding treatments
based on clinical circumstances and
medical possibilities
Goals of Care Discussions:
Advance Care Plans/POLST
 Advance
Directives/POLST forms are not ends in
themselves
 Goals
of care discussions for Advance
Directives/POLST forms are a process not just a onetime event meant to complete a form
OncFundamental Communication Skills (2002). Retrieved January 3, 2013 from
http://depts.washington.edu/oncotalk/learn/modules.html
-
Goals of Care Discussions
Important Considerations
Cultural
and Religious Diversity
Be
aware of variability in preferences
Remember that individuals preferences
within cultures and religions differ
Resource:
Doorway Thoughts
Goals of Care Discussion
Important Considerations
Decision-making
Detailed
style preferences:
vs. generalized information
Independent vs. shared decision making
Concerns about undertreatment vs.
overtreatment
Goals of Care Discussions
Important Considerations
Communication
Speech
difficulties
therapists may be able to provide
assistance
Resource: Communicating with Older Adults:
An Evidence-Based Review of What Really
Works
Goals of Care Discussions
Important Considerations
Cognitive
difficulties or loss
 Important
to assess the patient’s ability to
participate in the discussion and include the
patient as much as possible
 Discussions can be held in conjunction with
patient’s and caregivers
 Resource: Communicating with Older Adults: An
Evidence-Based Review of What Really Works
Potential Taboo Phrases:
Unintended Consequences
Phrase
Potential Consequence
Would you like us to restart your
heart if it stopped beating
Do you want us to do everything
possible to try to restart your
heart
Do not resuscitate
OncotFundamental Communication Skills (2002). Retrieved January 3, 2013 from
http://depts.washington.edu/oncotalk/learn/modules.html
Potential Taboo Phrases:
Unintended Consequences
Phrase
Potential Consequence
Would you like us to restart your
heart if it stopped beating
This may imply that CPR is risk
free and effective (“restart)
Do you want us to do everything
possible to try to restart your
heart
This may imply that the
alternative is to do nothing (“do
everything possible”)
Do not resuscitate
This may imply that an effective
treatment is being withheld (“do
not”)
Fundamental Communication Skills (2002). Retrieved January 3, 2013 from
http://depts.washington.edu/oncotalk/learn/modules.html
Persuasion (influence) vs.
Coercion (undue influence)
Using
persuasion to argue for
something we believe is in a patient’s
best interest is ethically permissible
Coercion - the use of force or threats is
not
"Do not punctuate the end of your life with a senseless act of brutality!" Retrieved January 3, 2013, form
http://www.cunniffdixon.org/do-not-punctuate-end-your-life-senseless-act-brutality
Influence vs. Undue Influence?
“Would you like us, in what would naturally be your
final moments, to press on your chest and break your
ribs, shove a tube down your throat and poke you
with needles in lots of places in a chaotic attempt that
has a very small chance of giving you more time to
be technically alive but unlikely to ever return to
meaningful communication with others?”
"Do not punctuate the end of your life with a senseless act of brutality!" Retrieved January 3, 2013, form
http://www.cunniffdixon.org/do-not-punctuate-end-your-life-senseless-act-brutality
Million Dollar Question
How
do you discuss code status with
patients?
What
you write will be collected and
reviewed for group discussion
Million Dollar Question
“You do not really understand
something unless you can
explain it to your grandmother.”
- Albert Einstein
Recommended Elements of a
Code Status Discussion:
 Introduction
 Investigate
patients’ goals, values, expectations
 Ensure patient understands their prognosis
 Explain nature, risks, and outcomes of CPR
 Make a recommendation re CPR consistent with patient’s
prognosis and goals of care
 Close Conversation
Anderson WG, et al. Code Status Discussions Between Attending Hospitalist Physicians and Medical
Patients at Hospital Admission. J Gen Intern Med. 2011 April; 26(4): 359–366
Million Dollar Answer
Potential Alternative Phrases:
Phrase
Would you like us to restart your
heart if it stopped beating
Do you want us to do everything
possible to try to restart your
heart
Do not resuscitate
Alternatives
“At some point in everyone’s life
their heart stops beating and they
stop breathing, have you thought
about what you would want when
this time comes?”
“Do not attempt resuscitation”
“Allow natural death”
Resources
Medical
College of Wisconsin Fast Facts:
http://www.eperc.mcw.edu/EPERC/FastFactsa
ndConcepts
Oncotalk:
http://depts.washington.edu/oncotalk/learn/mo
dules.html
Conversation
Project:
http://theconversationproject.org
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