CPR choices of dialysis patients suggest many lack context

August 24, 2020

Globally some 2 million people with failed kidneys undergo hemodialysis treatment. Their survival depends on being connected to a blood-cleansing machine, usually three times a week for three to four hours each time. The regimen can be grueling and limit patients' ability to travel far from home.

With this backdrop, researchers queried 876 dialysis patients about whether, in the event of a cardiac arrest, they would want to be resuscitated. Nearly 85% said they definitely or probably would want CPR, according to a paper published today in JAMA Network Open.

The respondents' appreciation for life should be recognized, the study's lead author said, but the findings also raise concern that many patients are unaware of important context that should inform such a preference.

"People who live with kidney failure are much more likely to develop cardiovascular problems than the general population, and their median survival after a cardiac arrest is five months, compared with almost three years for the general population. Among survivors, only 8% to 15% live for more than a year," said Dr. Gwen Bernacki, an acting instructor of cardiology at the University of Washington School of Medicine.

In the study, patients were not pre-informed of the likely poor outcomes in these circumstances. The survey results led Bernacki to infer that such consequential conversations are not happening enough between doctors and patients who receive dialysis.

"What's in question is whether this patient population understands their likely quality of life, should they survive a cardiac arrest. There should be a broader discussion about resuscitation in the setting of receiving dialysis," she said. "Engaging dialysis patients in difficult conversations topics is every provider's job, but it may be that too few of us are comfortable broaching sensitive topics. Most of us aren't trained in palliative care."

The concern is that these conversations are not happening at all, or that CPR is a topic overlooked in discussions about possible outcomes and patients' wishes for future care.

The study posed secondary questions about patients' preference for mechanical ventilation, whether longevity or comfort is prioritized in their future care, and whether they had considered stopping dialysis. Some participants' responses to the main CPR question seemed disconnected from responses to secondary questions, Bernacki observed - supporting her assertion that patients' choices about CPR probably were not informed by bigger-picture considerations about what is most important to them.

For instance, 43% of patients who desired resuscitation also wanted future care to focus on comfort, even though CPR aligns more logically with longevity-focused care (which was prioritized by 23% of those desiring CPR). Also, 25% of those who wanted CPR did not want mechanical ventilation, despite the fact that CPR often involves intubation - the placement of a tube through the mouth and into the airway.

Among patients who wanted no resuscitation efforts, only 60% had documented those wishes. "That's concerning because resuscitation is often done by default and so if not documented, CPR might happen automatically even if this not what patients want," Bernacki said.
The research was supported by the National Heart, Lung, and Blood Institute (T32HL125195-04) and the National Institute of Diabetes and Digestive and Kidney Diseases (U01DK102150).

University of Washington Health Sciences/UW Medicine

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