Cardiopulmonary Resuscitation Preferences of People Receiving Dialysis

Gwen M Bernacki, Ruth A Engelberg, J Randall Curtis, Manjula Kurella Tamura, Lyndia C Brumback, Danielle C Lavallee, Elizabeth K Vig, Ann M O'Hare, Gwen M Bernacki, Ruth A Engelberg, J Randall Curtis, Manjula Kurella Tamura, Lyndia C Brumback, Danielle C Lavallee, Elizabeth K Vig, Ann M O'Hare

Abstract

Importance: Whether the cardiopulmonary resuscitation (CPR) preferences of patients receiving dialysis align with their values and other aspects of end-of-life care is not known.

Objective: To describe the CPR preferences of patients receiving dialysis and how these preferences are associated with their responses to questions about other aspects of end-of-life care.

Design, setting, and participants: Cross-sectional survey study of a consecutive sample of patients receiving dialysis at 31 nonprofit dialysis facilities in 2 US metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 22, 2015, and October 2, 2018. Analyses for this article were conducted between December 2018 and April 2020.

Exposures: Participants were asked to respond to the question "If you had to decide right now, would you want CPR if your heart were to stop beating?" Those who indicated they would probably or definitely want CPR were categorized as preferring CPR.

Main outcomes and measures: This study examined the association between preference for CPR and other treatment preferences, engagement in advance care planning, values, desired place of death, expectations about prognosis, symptoms, and palliative care needs.

Results: Of the 1434 individuals invited to complete the survey, 1009 agreed to participate, and 876 were included in the analytic cohort (61.1%). The final cohort had a mean (SD) age of 62.6 (14.0) years; 492 (56.2%) were men, and 528 (60.3%) were White individuals. Among 738 of 876 participants (84.2%) who indicated that they would definitely or probably want CPR (CPR group), 555 (75.2%) wanted mechanical ventilation vs 13 of 138 (9.4%) of those who did not want CPR (do not resuscitate [DNR] group) (P < .001). A total of 249 of 738 participants (33.7%) in the CPR group vs 84 of 138 (60.9%) in the DNR group had documented treatment preferences (P < .001). In terms of values about future care, 171 participants (23.2%) in the CPR group vs 5 of 138 (3.6%) in the DNR group valued life prolongation (P < .001); 320 in the CPR group (43.4%) vs 109 of 138 in the DNR group (79.0%) valued comfort (P < .001); and 247 participants (33.5%) in the CPR group vs 24 of 138 (17.4%) in the DNR group were unsure about their wishes for future care (P < .001). In the CPR group, 207 (28.0%) had thought about stopping dialysis vs 62 of 138 (44.9%) in the DNR group (P < .001), and 181 (24.5%) vs 58 of 138 (42.0%) had discussed stopping dialysis (P = .001). No statistically significant associations were observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs.

Conclusions and relevance: The CPR preferences of patients receiving dialysis were associated with some, but not all, other aspects of end-of-life care. How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR preference. More work is needed to integrate discussions about code status with bigger picture conversations about patients' values, goals, and preferences for end-of-life care.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Bernacki reported receiving grants from the National Heart, Lung, and Blood Institute (NHLBI). Dr Engelberg reported receiving grants from the NHLBI (T32HL125195-04) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (U01DK102150). Dr Curtis reported receiving grants from Cambia Health Foundation and the National Institutes of Health (NIH). Dr Brumback reported grants from Cambia Health Foundation and the NIH. Dr O’Hare reported receiving grants or personal fees from the American Society of Nephrology, Centers for Disease Control and Prevention, Chugai Pharmaceutical Co, Ltd, Coalition for Supportive Care of Kidney Patients, Dialysis Clinic Inc, DEVENIR Foundation, Fresenius Medical Care, Hammersmith Hospital, Health and Aging Policy Fellows Program, Japanese Society for Dialysis Therapy, Kaiser Permanente Northern California, NIDDK, University of California San Francisco, University of Pennsylvania, UpToDate, and VA Health Services Research and Development Service. No other disclosures were reported.

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