Rosemarie Hakim

Preferences for cardiopulmonary resuscitation - Physician-patient agreement and hospital resource use

OBJECTIVE: To describe the association between hospital resource utilization and physicians’ knowledge of patient preferences for cardiopulmonary resuscitation (CPR) among seriously ill hospitalized adult patients.DESIGN: Prospective cohort study.SETTING: Five U.S. academic medical centers, 1989–1991.PATIENTS: A sample of 2,636 patients with self- or surrogate interviews and matching physician interviews describing patient preferences for CPR, from a cohort of 4,301 patients with life-threatening illnesses enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).MEASURES: Patient, surrogate, and physician reports of preferences for resuscitation, and resource use derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1990 dollars.RESULTS: Nearly one-third of the patients preferred to forge resuscitation. Of the 2,636 paired physician—patient answers, nearly one-third did not agree about preferences for resuscitation. The physicians’ views of the patients’ preferences and those preferences themselves were both associated with resource use. Standardized adjusted hospital resource consumption, expressed as average cost in dollars during the enrollment hospitalization, was lowest when the physician agreed with the patient preference for a do-not-resuscitate order (

Physician Understanding Of Patient Resuscitation Preferences: Insights and Clinical Implications

20,527), and highest when the patient did not have a preference and the physician believed the patient wanted resuscitation in the case of a cardiopulmonary arrest (

A comparison of risks and outcomes for patients with organ system failure : 1982-1990

34,829) Hospital resource use was intermediate when patient—physician pairs evidenced either lack of agreement or communication, or awareness of options about resuscitation.CONCLUSIONS: Both physician and patient preferences for CPR influence total hospital resource consumption. Physician misunderstanding of patient preferences to forgo CPR was associated with increased use of hospital resources, and could have led to a course of care at odds with patients’ expressed preferences in the event of cardiac arrest. Increasing physicians’ knowledge of patient preferences, and increasing communication to help patients understand that options foi medical care that include forgoing resuscitation efforts, might reduce hospital expenditures for the seriously ill.

The SUPPORT Prognostic Model: Objective Estimates of Survival for Seriously Ill Hospitalized Adults

OBJECTIVE: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in‐hospital CPR.

The Impact of Serious Illness on Patients' Families

OBJECTIVES To compare the outcomes for patients with one or more organ system failures treated in 1988 to 1990 with those outcomes from 1979 to 1982; to document risk factors for developing organ system failure; and investigate the relationship of these factors to hospital survival. DESIGN Prospective, multicenter, inception cohort analysis. SETTING Sixty intensive care units (ICUs) at 53 U.S. hospitals. PATIENTS A total of 17,440 ICU admissions treated in 1988 to 1990 and 5,677 ICU admissions treated in 1979 to 1982. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS At the time of organ system failure, patients were classified by demographic, physiologic, and diagnostic information. The type and number of organ system failures and physiologic responses were recorded for < or = 7 days of ICU treatment, and all patients were followed for status at hospital discharge. Hospital survival and the prognostic value of assessing the number of organ system failures were compared with risk assessment, based on use of a prognostic scoring system that estimated the patients probability of hospital mortality. The incidence of organ system failure (48%) among patients treated in 1988 to 1990 was similar (44%) to the occurrence rate in patients in 1979 to 1982; and an identical proportion (14%) developed multiple organ system failure. There was a significant (p < .0003) improvement in hospital mortality for patients with three or more organ system failures on day 4 or later of organ system failure. However, overall hospital mortality rates from multiple organ system failure were not different over this 8-yr period. The most important predictor of hospital mortality was the severity of physiologic disturbance on the initial day of failure. Discrimination of patients by risk of hospital mortality was better using the prognostic scoring system on day 1 of organ system failure (receiver operating characteristic curve = 0.88) than using a model based on the number of organ system failures (receiver operating characteristic curve = 0.68). CONCLUSIONS Organ system failure remains a major contributor to death in patients in ICUs. The incidence and overall outcome have not significantly changed over the past 8 yrs, but there has been significant improvement in survival for patients with persistent severe organ system failure. A continuous measure of individual patient severity of illness is a more sensitive and accurate method for describing patients and estimating outcome than counting the number of organ system failures.