Educational video helps terminal cancer patients decide whether to receive CPR

December 10, 2012

Patients with terminal cancer who viewed a three-minute video demonstrating cardiopulmonary resuscitation (CPR) were less likely to indicate a preference for receiving CPR in the event of an in-hospital cardiac arrest than were patients who only listened to a verbal description of the procedure. The study that will appear in the Journal of Clinical Oncology and is being released online today is a follow-up to a smaller, 2009 study and includes a more diverse group of patients with many forms of cancer.

"It really is incumbent on us, as physicians, to help our patients understand their options at the end of life," says Angelo Volandes, MD, MPH, of the Massachusetts General Hospital (MGH) Department of Medicine, corresponding author of the current report. "Our results clearly show that educational videos can help supplement - not supplant - the patient/doctor relationship by reinforcing, not replacing, the conversations that must take place between doctors and patients."

The earlier study enrolled only patients with brain cancer, which represents less than 1 percent of cancer diagnoses, who were treated at the MGH Cancer Center. The current investigation - called the Video Images of Disease for Ethical Outcomes (VIDEO) study - was extended to patients at Boston Medical Center, Queens Hospital Cancer Center in New York, and Vanderbilt-Ingram Cancer Center in Nashville. All of the patients in the 2009 study were white, while one third of those in the current study were African American and 10 percent Hispanic. The previous study presented patients with information about a range of end-of-life decisions, but the current study focused on the choice to receive CPR, a decision, Volandes explains, that can have a major impact on the course of a patient's care.

At each of the four centers, cancer patients who were aware that their prognosis was less than one year were invited to participate in the study immediately after a scheduled clinic visit. Those agreeing to participate first completed a questionnaire including details of their personal background and their current preferences regarding CPR. They then were randomized into two groups, completed assessments of their current knowledge about CPR and general health information, and listened to identical verbal narratives describing the goals, processes and risks of CPR - including the likelihood of successful resuscitation in patients with advanced cancer.

One group then watched the video, which included images of a simulated CPR procedure conducted on a mannequin and of a real patient on mechanical ventilation receiving intravenous medication. (The video can be viewed at http://www.acpdecisions.org/#&panel1-4.) Both groups then completed a second questionnaire that once again ascertained their knowledge about CPR and asked the same questions regarding CPR preferences. Six to eight weeks later a member of the research team, who did not know to which group patients had been assigned, attempted to contact them by phone to adminster a follow-up questionnaire.

A total of 150 patients were enrolled at the four centers, 70 of whom viewed the video, while 80 were in the control group. Before beginning the study about half of those in both groups indicated they would choose to receive CPR. That preference dropped slightly - from 54 to 48 percent - among those who only listened to the verbal description of CPR, but among those who also viewed the video, the preference for CPR dropped by more than half - from 49 percent to 20 percent.

Successful follow-up calls were made to 67 participants - 30 who had viewed the video and 37 who had not. More than half of those in each group had died before the calls were placed. Among patients who were contacted, 17 percent of those who saw the video said they would choose to receive CPR, as did 41 percent of the controls. Among those who viewed the video, 90 percent indicated that it was helpful, 93 percent that they were comfortable viewing it, and 98 percent said they would probably or definitely recommend viewing the video to other patients with advanced cancer.

"We now have even more evidence that videos are more informative and, in combination with verbal discussion, give patients more knowledge with which to make these important decisions," says Volandes. "When patients have more knowledge, they tend not to want more aggressive interventions, and this effect persists over time. Not only were patients overwhelmingly comfortable viewing the videos, but those patients who had lower levels of health literacy were particularly likely to indicate that the video was helpful to them. We need to provide all patients with the tools to understand their treatment options, especially for end-of-life care."
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An assistant professor of Medicine at Harvard Medical School, Volandes is also co-founder of Advanced Care Planning Decisions, a non-profit foundation developing and researching video decision support tools and making them available to the health care community. Currently 35 health systems are using the organization's videos as part of their standard of care for patients with advanced diseases. This study is one of a series being conducted by the Video Images of Disease for Ethical Outcomes (VIDEO) Consortium, which includes more than 100 physicians, nurses, patients and video artists from 10 academic medical centers across the country, currently studying the use of videos for decision support in patients with heart failure, end-stage kidney disease and other leading causes of death in the U.S.

The study was support by grant K08HS018780 from the Agency for Healthcare Research and Quality and grant 0177-1 from the Informed Medical Decisions Foundation. Senior author of the report is Jennifer Temel, MD, MGH Cancer Center. Additional co-authors include Areej El-Jawahri, Michael Barry, Vicki Jackson, Elizabeth Walker-Corkery, Yuchiao Chang and Lenny López, Massachusetts General Hospital; Michael Paasche-Orlow, Kevan Hartshorn, Boston University School of Medicine; Susan Mitchell, Hebrew Senior Life; Muriel Gillick, Harvard Pilgrim Health Care; Margaret Kemeny and Linda Bulone, Queens Hospital Cancer Center; Andrew Epstein and Ariela Noy, Memorial Sloan-Kettering Comprehensive Cancer Center; Sumi Misra and Matt Peachey,Vanderbilt University Medical Center; and Elmer Abbo, University of Chicago

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $750 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, transplantation biology and photomedicine. In July 2012, MGH moved into the number one spot on the 2012-13 U.S. News & World Report list of "America's Best Hospitals."

Massachusetts General Hospital

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