Elderly patients at risk for unwanted CPR: study

Canadian hospitals put patients at risk of unwanted CPR by failing to accurately record their preference for the treatment, says a new study.

Researchers from Queen’s University and the University of British Columbia found that patient choices related to cardiopulmonary resuscitation were inaccurately documented in 37 per cent of cases.

“Many patients are at risk of receiving inappropriate end-of-life care,” they wrote in the scientific journal BMJ Quality & Safety. “These discordances are medical errors.”

Since 2012, hospitals in British Columbia have introduced a new policy to address the problem, according to a leading palliative-care physician. The policy is aimed at promoting better communication between doctors and patients.

The Queen’s and UBC researchers interviewed elderly patients in acute care at 16 major hospitals across Canada and compared patients’ preference for CPR with what doctors recorded in their orders. They concluded that errors were “very common.”

Dr. Peter Dodek, one of the authors of the study, said there are many reasons errors may happen.

“It could be that the patient didn’t disclose [his or her preference] to the clinician. It could be that the clinician didn’t ask, or… it didn’t come up in the discussion,” said Dodek, professor of critical-care medicine at UBC.

The study indicates that errors in doctors’ orders could lead to inappropriate treatment. In the majority of these cases, patients who don’t want CPR may receive it. In a very small proportion of cases, patients who do want CPR may not get it.

Many elderly people decide that they don’t want CPR if their hearts stop.

CPR can be painful for patients and stressful for family members who are present. According to end-of-life planning pamphlets prepared by Fraser Health Authority, only two to three patients out of 20 who undergo CPR will survive. Of those who survive, only one in 20 will recover well enough to return home.

Of the 808 patients who took part in the study, only 12 per cent said they would prefer to get CPR.

Joan Straight, a 95-year-old Vancouver retiree, said she doesn’t want CPR either. She wants to die quietly and comfortably.

“I sort of want to let happen what happens. It’s better to just drift off,” said Straight, a former ballet dancer.

Straight said her doctor never asked whether she would want CPR. She had to bring it up on her own — a demonstration of how communications on this uncomfortable topic can easily break down.

Sue Hughson said the study’s findings confirm what she has previously heard only anecdotally. Hughson is a member of the board of directors of Dying with Dignity Canada, an organization that advocates for patient choice in end-of-life care.

“We’re really trying to get people to have this discussion about end-of-life and advance care planning so that we can minimize these impacts,” Hughson said.

Four hospitals in B.C. were included in the study: Vancouver General Hospital, St. Paul’s Hospital, Burnaby Hospital and Royal Columbian Hospital. The study found rates of error varied widely between hospitals, from 14 per cent at the lowest to 82 per cent at the highest. The study did not report rates of error for individual hospitals.

Dodek said differences in protocols and institutional culture between hospitals may account for the variability.

“In some places, it’s completely informal. There’s no explicit pathway,” Dodek said. In other hospitals, there are clear protocols for asking patients about their end-of-life wishes.

Dr. Doris Barwich, executive director of the BC Centre for Palliative Care, said hospitals in B.C. have a relatively robust policy for discussing end-of-life decisions with patients. The policy, Medical Orders for Scope of Treatment, was first implemented by Fraser Health Authority in 2012 and later adopted by other B.C. health regions.

The policy seeks to address what Barwich describes as a “translation problem.” A doctor may interpret a patient’s priorities differently, resulting in orders for unwanted treatments. Barwich said MOST standardizes how end-of-life decisions are recorded. That allows for more thorough conversations between doctors and patients and improves understanding.

“We’re all talking about the same thing and using the same language. We should see less confusion and less gaps in the translation of people’s values and preferences into medical orders,” Barwich said.

Dodek said future research will focus on figuring out why these errors happen and finding ways to improve communication between patients and doctors.