Video may help terminal patients make CPR choice

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Terminally ill cancer patients who watched either of two videos about the option to forego resuscitation overwhelmingly elected that route for the patient in the video, if not for themselves, according to a new study.

But the vignettes - whose only difference was whether fictional patients decided on their own to skip cardiopulmonary resuscitation (CPR) or got a recommendation from their doctor - elicited high marks from real patients for the video doctors' compassion in discussing a difficult subject.

Importantly, study participants didn't think less of a doctor who recommended that patients forgo life-saving efforts during cardiac arrest.

"The reassuring finding here is that both approaches (doctor- versus patient-guided decisions about whether to be resuscitated) are likely to reach very similar results," said study author Dr Eduardo Bruera, department chair of palliative care and rehabilitation medicine in the cancer medicine division at the University of Texas MD Anderson Cancer Center in Houston.

Dying cancer patients can survive cardiac arrest if given CPR, but experts note that most of those patients will suffer from serious complications and typically die within days to weeks.

The alternative is for a patient to request in advance not to be resuscitated in a crisis. However, experts find that most cancer patients do not have conversations with their doctors about whether they want CPR in an emergency.

Bruera and his colleagues wanted to test approaches to such conversations and see whether patients would rather be advised what to do or to make up their own minds after hearing the information.

How the study was done

In the study, 78 patients with advanced cancer at MD Anderson watched two videos depicting a middle-aged doctor telling a woman in her 60s with cancer about resuscitation options.

In one video, the doctor recommended a do-not-resuscitate option, whereas in a nearly identical video, the doctor asked whether the patient wanted to opt out of CPR.

All 30 study patients who had already requested do-not-resuscitate orders for themselves chose the same for the patient depicted in the video. Among the 48 patients who hadn't made any CPR decisions, 30 chose the option for the patient in the video.

Factors such as age, gender or socioeconomic status were not linked to patients' do-not-resuscitate decisions, researchers found.

Only three patients had had a conversation about resuscitation with their doctors, according to the report that appears in the journal Cancer.

"Patients might be willing to make that decision for themselves if the conversation occurs, they just haven't had the conversation with their doctors yet," Bruera said.

Researchers have already tested videos in clinics as a way to inform patients about the realities of CPR and reduce patient requests for it.

"The use of video technology rather than simply a conversation or giving people a piece of paper might provide patients with access to information in a much more effective way," Bruera said.

"The potential is for videos to be an educational tool before having a personalised conversation."

Icebreakers

For time-strapped doctors, having the sensitive talk about end-of-life options is difficult and doctors frequently cite their fear that the conversation will make them appear uncompassionate to patients, experts said.

But the high compassion scores patients in the study gave to the video doctors could be seen as a sign of appreciation for the conversation taking place in any form, wrote Rebecca Pentz and Anne Lederman Flamm of Emory University School of Medicine in Atlanta in an accompanying editorial.

Videos may act as icebreakers, but won't replace the crucial human interaction, according to Dr Andrew Shuman, head and neck surgical fellow at Memorial Sloan-Kettering Cancer Center in New York.

"Using visual media to educate and guide end-of-life decision-making may be quite useful, but in my opinion, will never replace the importance of direct and open communication between patients and clinicians," said Shuman, who was not involved in the study.

"Unfortunately, many clinicians are not comfortable addressing end-of-life decisions with patients due to issues involving lack of training in how to have these difficult conversations, uncertainties in estimating prognosis, and the (often erroneous) perception that patients do not want to discuss these issues either," he said.

Another expert questioned the study's impact on clinical practices since patients made do-not-resuscitate decisions for another person and not themselves.

"Whether (this study) really translates into an action item for healthcare professionals remains uncertain," said Dr Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society.

"There's a bit of a distance between saying what someone else should do versus how they might respond to their own situation," Lichtenfeld said.

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