Communication Interventions May Alter Patients' DNR Decisions

By Marilynn Larkin

June 15, 2019

NEW YORK (Reuters Health) - Communication interventions such as pamphlets, discussions, videos about cardiopulmonary resuscitation (CPR), handouts about advanced directives and interviews by trained facilitators may alter patient decisions regarding do-not-resuscitate (DNR) orders, researchers say.

Dr. Sabina Hunziker of University Hospital Basel in Switzerland and colleagues searched the literature for randomized controlled trials of communication interventions during code status discussions.

A total of 7,001 records were identified. After de-duplication and screening, 15 studies were eligible for inclusion.

As reported online June 7 in JAMA Network Open, all 15 trials (2,405 patients) were included in the qualitative synthesis, 11 trials (1,463) were included for the quantitative synthesis of the primary endpoint (patient preference for CPR), and five trials (652 patients) were included for the secondary endpoint (patient knowledge regarding life-sustaining treatment).

Compared with control groups, intervention groups had significantly lower preference for CPR (53.6% vs. 38.6%; risk ratio, 0.70).

In a subgroup analysis, compared to other interventions, resuscitation videos as decision aids were associated with a stronger decrease in preference for life-sustaining treatment (RR, 0.56 vs. 1.03). Further, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55).

"Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions," the authors conclude.

Dr. Gavin Perkins of Warwick Medical School in the UK, coauthor of a related editorial, told Reuters Health the review "accepted the premise that the decision whether or not to attempt CPR is considered on its own."

"In fact," he said by email, "acute deterioration and cardiac arrest are rarely unheralded events. Having conversations in advance about what outcomes patients value - and which ones they fear - provides the opportunity to discuss which treatment options might be of benefit to them."

"In the UK, ReSPECT ( provides a framework for discussing and recommending emergency care treatment options including resuscitation," he added. "Future research should focus on the optimal approach to overall treatment plans, rather than 'Do not attempt CPR' in isolation."

Dr. M. Sara Rosenthal, Founding Director, Program for Bioethics and the MCC Oncology Ethics Program and Chair, Hospital Ethics Committee at the University of Kentucky in Lexington, commented by email, "The study seems consistent with what we see in practice: patients frequently do not have a clear understanding or appreciation of what 'full code' or CPR means, and what the risks of CPR can entail, which can include broken ribs, a collapsed lung, or a neurological injury due to lack of oxygen."

"A DNR order is typically suggested in situations where a patient is not considered a good medical candidate for CPR because the risks can outweigh any potential benefit," she told Reuters Health.

"What we don't know (about these studies) is who was making the code-status decision, and whether the communication interventions were provided to surrogate decision-makers of patients who did not have decision-making capacity," she said. "If the request to be 'full code' is coming from a surrogate decision-maker, the medical team needs to ensure that the surrogate also understands and appreciates the consequences of that decision."

"Many patients or their surrogates request 'full code' because they fear that 'DNR' means 'do not treat' or will lead to abandonment, which is not all the case," she noted. "Finally, an important caveat is time: there is often not enough time to fully educate decision-makers about what CPR entails when an urgent decision must be made."

"Code-status decisions should be made as early as possible, which can be done with an advance directive, or simply as a documented discussion in the chart," she added. "But the most important decision patients need to make upon admission to a hospital is designating a surrogate decision-maker because that is the person who will most likely be making consequential code status decisions on their behalf."

Dr. Hunziker did not respond to requests for a comment.


JAMA Netw Open 2019.