Many heart failure (HF) patients change their final resuscitation decisions close to the end of life, often while in the hospital. The findings may help cardiologists better counsel these patients.
The study enrolled 603 patients between 2007 and 2011 with a mean 2.7-year follow-up. Of those enrolled, 237 died during follow-up. At the time of enrollment, 73.4 percent made the decision for a Full Code as opposed to signing do-not-resuscitate (DNR) orders. At the time of death, 78.5 percent had elected DNR status. DNR decisions were made in the final days to weeks of life.
Not all decisions were ultimately in favor of DNR. “Overall, 274 (45.1 percent) patients were DNR at some point during follow-up, 28.8 percent of whom changed back to Full Code at least once after being DNR,” wrote the researchers, led by Shannon M. Dunlay, MD, MS, of the Mayo Clinic in Rochester, Minn. They stressed that “a do-not-resuscitate preference is not an independent risk factor for death, but rather, the excess mortality risk was explained by comorbidity and poor health status.”
In fact, much of the decision making and end-of-life discussions between HF patients and their doctors, they found, did not occur until much later in the illness trajectory. This is due, in part, to the episodic nature of HF not found in other terminal illnesses.
“Physicians are often wary of discussing prognosis and end of life care for fear of causing alarm and destroying hope,” Dunlay et al wrote. “As a result most patients with HF have little understanding about their prognosis.” This has led to an overestimation of survival and recovery outcomes, which may have affected decision making.
While not an optimal time from the patients’ perspective, most DNR decisions are made when hospitalized.
“It is best if advanced care decisions have been previously discussed in an outpatient setting and can be reviewed and updated on hospital admission,” Dunlay et al stated. While HF patients’ resuscitation preferences change over time, discussion of care and treatment should be “an ongoing, iterative process, considered in the context of an individual’s specific health status, available therapeutic options, and personal beliefs.”
These results were published online May 13 in Circulation: Cardiovascular Quality and Outcomes.