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

Renee D. Stapleton; Dee W. Ford; Katherine R. Sterba; Nandita R. Nadig; Steven Ades; Anthony L. Back; Shannon S. Carson; Katharine L. Cheung; Janet Ely; Erin K. Kross; Robert C. Macauley; Jennifer M. Maguire; Theodore W. Marcy; Jennifer J. McEntee; Prema R. Menon; Amanda Overstreet; Christine S. Ritchie; Blair Wendlandt; Sara S. Ardren; Michael Balassone; Stephanie Burns; Summer Choudhury; Sandra Diehl; Ellen McCown; Elizabeth L. Nielsen; Sudiptho R. Paul; Colleen Rice; Katherine K. Taylor; Ruth A. Engelberg

doi:10.1016/j.jpainsymman.2022.03.009

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

Renee D. Stapleton^*, Dee W. Ford, Katherine R. Sterba, Nandita R. Nadig, Steven Ades, Anthony L. Back, Shannon S. Carson, Katharine L. Cheung, Janet Ely, Erin K. Kross, Robert C. Macauley, Jennifer M. Maguire, Theodore W. Marcy, Jennifer J. McEntee, Prema R. Menon, Amanda Overstreet, Christine S. Ritchie, Blair Wendlandt, Sara S. Ardren, Michael BalassoneStephanie Burns, Summer Choudhury, Sandra Diehl, Ellen McCown, Elizabeth L. Nielsen, Sudiptho R. Paul, Colleen Rice, Katherine K. Taylor, Ruth A. Engelberg

^*Corresponding author for this work

Medicine, Pulmonary Division

Research output: Contribution to journal › Article › peer-review

1 Scopus citations

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.

Original language	English (US)
Pages (from-to)	e621-e632
Journal	Journal of Pain and Symptom Management
Volume	63
Issue number	6
DOIs	https://doi.org/10.1016/j.jpainsymman.2022.03.009
State	Published - Jun 2022

Funding

RDS, DWF, ELN, KKT, and RAE were supported by both the National Palliative Care Research Center and the National Institutes of Health (NIH) for this research. KRS, SD, and EM were supported by the National Palliative Care Research Center for this research. NRN, SSC, KLC, EKK, RCM, JMM, JJE, PRM, AO, CSR, BW, SSA, MB, SB, SC, SRP, and CR were supported by the NIH for this work. SA, ALB, JA, and TWM have nothing to disclose. With immense professional love and gratitude, we wish to acknowledge Dr. Randy Curtis for the crucial role he has selflessly played in this body of work for 15 years. Were it not that this issue of JPSM in honor of him is a surprise, he would have been a co-author of this manuscript. Randy has been an extraordinary mentor, sponsor, coach, and friend, and we are forever grateful that he has made us better academicians, researchers, physicians, and human beings. This work was supported by the National Palliative Care Research Center (grant title “Changing the paradigm of CPR: Exploring Informed Assent”) and the National Institutes of Health (R01AG050698). RDS, DWF, ELN, KKT, and RAE were supported by both the National Palliative Care Research Center and the National Institutes of Health (NIH) for this research. KRS, SD, and EM were supported by the National Palliative Care Research Center for this research. NRN, SSC, KLC, EKK, RCM, JMM, JJE, PRM, AO, CSR, BW, SSA, MB, SB, SC, SRP, and CR were supported by the NIH for this work. SA, ALB, JA, and TWM have nothing to disclose. This work was supported by the National Palliative Care Research Center (grant title “Changing the paradigm of CPR: Exploring Informed Assent”) and the National Institutes of Health ( R01AG050698 ).

Keywords

Code status
cardiopulmonary resuscitation
communication
end-of-life
seriously ill patients

ASJC Scopus subject areas

General Nursing
Clinical Neurology
Anesthesiology and Pain Medicine

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Stapleton, R. D., Ford, D. W., Sterba, K. R., Nadig, N. R., Ades, S., Back, A. L., Carson, S. S., Cheung, K. L., Ely, J., Kross, E. K., Macauley, R. C., Maguire, J. M., Marcy, T. W., McEntee, J. J., Menon, P. R., Overstreet, A., Ritchie, C. S., Wendlandt, B., Ardren, S. S., ... Engelberg, R. A. (2022). Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients. Journal of Pain and Symptom Management, 63(6), e621-e632. https://doi.org/10.1016/j.jpainsymman.2022.03.009

@article{77481ea44e7848189438314401825dbc,

title = "Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients",

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",

author = "Stapleton, {Renee D.} and Ford, {Dee W.} and Sterba, {Katherine R.} and Nadig, {Nandita R.} and Steven Ades and Back, {Anthony L.} and Carson, {Shannon S.} and Cheung, {Katharine L.} and Janet Ely and Kross, {Erin K.} and Macauley, {Robert C.} and Maguire, {Jennifer M.} and Marcy, {Theodore W.} and McEntee, {Jennifer J.} and Menon, {Prema R.} and Amanda Overstreet and Ritchie, {Christine S.} and Blair Wendlandt and Ardren, {Sara S.} and Michael Balassone and Stephanie Burns and Summer Choudhury and Sandra Diehl and Ellen McCown and Nielsen, {Elizabeth L.} and Paul, {Sudiptho R.} and Colleen Rice and Taylor, {Katherine K.} and Engelberg, {Ruth A.}",

note = "Publisher Copyright: {\textcopyright} 2022 American Academy of Hospice and Palliative Medicine",

year = "2022",

month = jun,

doi = "10.1016/j.jpainsymman.2022.03.009",

language = "English (US)",

volume = "63",

pages = "e621--e632",

journal = "Journal of Pain and Symptom Management",

issn = "0885-3924",

publisher = "Elsevier Inc.",

number = "6",

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Stapleton, RD, Ford, DW, Sterba, KR, Nadig, NR, Ades, S, Back, AL, Carson, SS, Cheung, KL, Ely, J, Kross, EK, Macauley, RC, Maguire, JM, Marcy, TW, McEntee, JJ, Menon, PR, Overstreet, A, Ritchie, CS, Wendlandt, B, Ardren, SS, Balassone, M, Burns, S, Choudhury, S, Diehl, S, McCown, E, Nielsen, EL, Paul, SR, Rice, C, Taylor, KK & Engelberg, RA 2022, 'Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients', Journal of Pain and Symptom Management, vol. 63, no. 6, pp. e621-e632. https://doi.org/10.1016/j.jpainsymman.2022.03.009

TY - JOUR

T1 - Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

AU - Stapleton, Renee D.

AU - Ford, Dee W.

AU - Sterba, Katherine R.

AU - Nadig, Nandita R.

AU - Ades, Steven

AU - Back, Anthony L.

AU - Carson, Shannon S.

AU - Cheung, Katharine L.

AU - Ely, Janet

AU - Kross, Erin K.

AU - Macauley, Robert C.

AU - Maguire, Jennifer M.

AU - Marcy, Theodore W.

AU - McEntee, Jennifer J.

AU - Menon, Prema R.

AU - Overstreet, Amanda

AU - Ritchie, Christine S.

AU - Wendlandt, Blair

AU - Ardren, Sara S.

AU - Balassone, Michael

AU - Burns, Stephanie

AU - Choudhury, Summer

AU - Diehl, Sandra

AU - McCown, Ellen

AU - Nielsen, Elizabeth L.

AU - Paul, Sudiptho R.

AU - Rice, Colleen

AU - Taylor, Katherine K.

AU - Engelberg, Ruth A.

PY - 2022/6

Y1 - 2022/6

N2 - 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.

AB - 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.

KW - Code status

KW - cardiopulmonary resuscitation

KW - communication

KW - end-of-life

KW - seriously ill patients

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ER -

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

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