Exploring and reconciling discordance between documented and preferred resuscitation preferences for hospitalized patients: a quality improvement study

Recherche et correction de la discordance entre les préférences documentées et réelles en matière de réanimation de patients hospitalisés : une étude d’amélioration de la qualité

Abstract

Purpose

A discordance, predominantly towards overtreatment, exists between patients’ expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time.

Methods

Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance.

Results

Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients.

Conclusion

Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.

Résumé

Objectif

Il existe une discordance, qui tend surtout vers un sur-traitement, entre les préférences exprimées par les patients pour les interventions de maintien de la vie et celles documentées lors de l’admission à l’hôpital. Cette étude d’amélioration de la qualité avait pour objectif d’évaluer cette discordance au sein de notre institution. Les objectifs secondaires de notre étude étaient d’explorer la possibilité que les équipes de médecine interne (MI) identifient les patients qui pourraient bénéficier de conversations approfondies et de voir si la discordance pouvait être corrigée en temps réel.

Méthode

Deux infirmières ont intégré des équipes de MI dans un hôpital tertiaire pour discuter avec les patients hospitalisés de leurs préférences en matière de réanimation entre le 1er août 2016 et le 31 août 2018; les patients leur étaient soit spécifiquement référés (groupe I, n = 165), ou sélectionnés au hasard (groupe II, n = 164). Les préférences en matière de réanimation ont été documentées et communiquées aux équipes, entraînant une révision des ordonnances de réanimation, le cas échéant. La régression logistique multivariée a été utilisée afin de déterminer les facteurs de risque potentiels de discordance.

Résultats

Trois cent vingt-neuf patients ont été évalués, d’un âge moyen (écart type) de 80 ans (12) et avec un score de 6,8 (2,6) à l’Indice de comorbidité de Charlson. Une discordance a été identifiée chez 63/165 (38 %) et 27/164 (16 %) patients dans les groupes I et II, respectivement. Au total, 42/194 patients (21 %) ne souhaitaient pas de réanimation cardiorespiratoire (RCR) et 15/36 (41 %) préféraient ne pas être admis à l’unité de soins intensifs (USI), malgré une mention dans leurs préférences initiales. Parmi les patients chez lesquels une discordance a été notée, 93 % (84/90) ont préféré une désescalade des soins. La discordance a pu être corrigée pour 77 % (69/90) des patients.

Conclusion

La documentation des patients hospitalisés pourrait indiquer des préférences pour des interventions de RCR et d’admission à l’USI contraires aux véritables préférences. Des infirmières formées à cet effet peuvent identifier les patients hospitalisés qui bénéficieraient d’une conversation approfondie sur leurs préférences en matière de réanimation. Une fois identifiée, une discordance peut être corrigée lors de l’admission initiale.

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Author contributions

Ravi Taneja, Robert Sibbald, and Mark Goldszmidt contributed significantly to this manuscript by making substantial contributions to study conception, study design, data acquisition, data analysis, and drafting and critically revising the manuscript. Launa Elliott contributed to study design, data collection, and drafting and revising the manuscript. Elizabeth Burke contributed to study design and data collection, and provided feedback on the draft revision of the manuscript. Kristen A. Bishop contributed significantly to this manuscript by making substantial contributions to the analysis of the data as well as drafting and critically revising the manuscript. Philip M. Jones contributed significantly to this manuscript by making substantial contributions to study conception, study design, data analysis, and drafting and critically revising the manuscript.

Acknowledgements

The authors thank Dr. W. Haddara (critical care), Dr. M. Mrkobrada (internal medicine) and all CTU staff at University Hospital, London Health Sciences Centre for collaborative efforts and helpful discussions as well as Dr. D. Bainbridge (anesthesia) for reviewing the manuscript.

Disclosures

None.

Funding

AMOSO Opportunities Grant (RT) # S15-001. AMOSO Innovations Grant (RT, RS) # INN17-003.

Editorial responsibility

This submission was handled by Dr. Alana M. Flexman, Associate Editor, Canadian Journal of Anesthesia.

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Correspondence to Ravi Taneja MD, FRCA, FRCPC.

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Taneja, R., Sibbald, R., Elliott, L. et al. Exploring and reconciling discordance between documented and preferred resuscitation preferences for hospitalized patients: a quality improvement study. Can J Anesth/J Can Anesth (2021). https://doi.org/10.1007/s12630-020-01906-y

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Keywords

  • cardiopulmonary resuscitation
  • shared decision-making
  • discordance
  • intensive care unit
  • resuscitation preference
  • advance care planning