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| Journal of the New Zealand Medical Association,
11-May-2012, Vol 125 No 1354
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Old Man’s Friend? Resuscitation decisions in
patients hospitalised with pneumonia
David G Tripp
Community-acquired pneumonia (CAP) is a common illness
leading to hospital admission, with over 8000 admissions per year in New Zealand
(265 per 100,000).1 Particularly in the elderly
CAP is also associated with significant inpatient and subsequent
mortality.2–4
Given this risk of death, it is relevant to consider the
timing and nature of discussions occurring with patients about their wishes in
the event of a life-threatening illness. Such discussion could allow those
caring for the patient to better understand their wishes regarding end-of-life
care. These discussions have been shown to improve patient satisfaction, the
quality of dying, and reduce psychological morbidity in family
members.5
The growth in the use of Do Not Resuscitate (DNR) orders
(also described as Do Not Attempt Resuscitation (DNAR)—the term is used in
this study6) amongst the elderly without
malignancy over recent decades is a worldwide trend, although it is unclear to
what extent this is driven by more explicit medical decision making, or by more
actively soliciting patients’ wishes.6
There are variations between countries in terms of
preferences for or against CPR, and whether patients wish to be involved in
decisions regarding resuscitation orders.7,8
These issues are set within a broader context of significant variation between
countries in the quality of and access to end-of-life
care.9
The aim of this study is to determine whether end-of-life
discussions occurred in patients with CAP where the risk of death was high on
the basis of simple prognostic factors.
MethodA retrospective audit was conducted of patients
discharged from Wellington and Kenepuru Hospitals with a primary diagnosis of
CAP. This audit was originally undertaken to assess the impact on the clinical
assessment and treatment of patients of the opening of its Medical Assessment
Unit in November 2009.10
Data was collected on 155 patients presenting January
to March 2009 and January to March 2010. Electronic and paper records were
reviewed. Data collected included the date of death if a patient died in New
Zealand within 12 months of discharge.
This data also included if discussions were had with
patients about their wishes in the event of a life threatening deterioration,
and if so whether the patient’s status was recorded as “For
resuscitation” (CPR) or “Do not attempt resuscitation”
(DNAR).
The presence of a resuscitation status was correlated
with a variety of variables, including age, illness severity and inpatient and
12-month mortality.
Severity of CAP was assessed using the CURB65
score.11 This is a prospectively validated
assessment score of the risk of 30 day mortality. A score of 0 is mild and 5 is
severe, with points given for respiratory rate >30, urea >7.4, the
presence of confusion, hypotension and age ≥ 65. CURB65 scores were only
recorded on 15% of admissions.
A retrospective CURB Age score was therefore calculated
for all patients. Where urea was not ordered, a point was given if the patient
had an acute rise in creatinine or was clinically assessed as dehydrated,
although it is acknowledged this is an imperfect substitute. Confusion was often
not documented. This calculated score may therefore understate average CURB
scores.
Results are reported below as aggregated data, with
“well” being a score of 0 or 1 (corresponding to mild CAP), and
“unwell” being a score of 2 or more (corresponding to moderate or
severe CAP). One point of the CURB65 score is allocated for age ≥ 65,
which therefore confounds comparisons between age and severity.
ResultsFigure 1 shows the inpatient and 12-month mortality by age
band and severity at presentation.
Inpatient mortality from pneumonia in those under 65 is
rare. All of the 4 patients under 65 who died either during admission or in the
subsequent 12 months had significant pre-existing comorbidities: 3 had liver
disease and one had end-stage renal failure on dialysis with a prior disabling
stroke.
In the 65–79 year old group, the CURB65 score
predicted the risk of inpatient but not 12-month mortality. The CURB65 score was
modelled to predict 30 day mortality and does not reflect the burden of chronic,
comorbid disease. It is therefore not unexpected that its efficacy declines over
time.
Total 12-month mortality rose steeply with age and
comorbidity. Of the 33 patients dying over 65, many had significant
comorbidities: 12 (36%) had extreme frailty or multiple comorbidities, 8 (24%)
had cancer, 2 (6%) had underlying lung disease, and 1 (3%) had liver
disease.
The presence of a resuscitation order for inpatient death
had a sensitivity of 100%, specificity of 68% and positive predictive value of
18%. Presence of a resuscitation order for subsequent death in those surviving
at discharge had a sensitivity of 46%, specificity of 74% and positive
predictive value of 29%.
Figure 1. 12-month mortality by age and
severity
 Table 1 details patient mortality and frequency of
documentation on resuscitation status in the event of arrest (either for CPR, or
DNAR).
The frequency of a documented resuscitation decision rose
steeply with age, peaking at 51% in patients over 80. This group had at 46%
12-month mortality.
Table 2 details the timing of resuscitation discussions of
those who died between admission and 12 months from discharge.
Table 1. Mortality and documented resuscitation
status by age
Table 2. Timing of resuscitation decisions in
those who died
DiscussionCAP treated as an inpatient is an illness with significant
associated mortality in those over 65. Mortality is greatest following
discharge. CAP, especially in those over 80 and regardless of its severity,
serves as a marker of significant post-discharge mortality. This is consistent
with former studies, the largest of which found a 40.9% 1 year mortality in
158,960 patients over 65 hospitalised with
CAP.4
Discussions about resuscitation status in the event of
in-hospital death are a small part of the potential breadth of advance care
planning discussions, but are used here as a marker that the clinician
considered end-of-life discussions to be appropriate.
Many guidelines recommend advance care planning for those
with a life expectancy of less than 1 year,12,
13 although many physicians report they would not discuss end-of-life
options with terminally ill patients who are feeling
well.14 While end-of-life discussions have been
commonly recommended in those with malignant disease, their proactive use is
increasingly recommended in patients with non-malignant chronic illness or
frailty.15 New Zealand rates well compared to
other countries with respect to awareness of end-of-life
options.9
For all the above patients, approximately one third had
discussions or decisions made about resuscitation status at some point during
their admission. This is comparable with other studies in
CAP.16
All those who died as inpatients had resuscitation orders in
place – reflecting the generally predictable decline in those who die due
to CAP as inpatients. This is consistent with other NZ studies showing
end-of-life discussions in the significant majority of people who die in
hospital during their terminal admission.2
Rates of end-of-life discussion were higher for those at
particular risk of death – both the elderly and those with severe CAP.
However, even in groups with high post-discharge mortality, end-of-life
discussions were only documented in a minority of cases. For example, those who
were over 65 and unwell had documented resuscitation statuses in 42% of cases,
despite a 12-month mortality in this group of 44%.
This data therefore suggests that the use of a DNAR order in
this institution acts more as a surrogate marker for impending death, than as a
process of soliciting the views about end-of-life care of those at risk of
dying.17, 18
There are a number of potential barriers which limit the
frequency of these discussions,19 including the
difficulty of choosing the “right”
time,17 over estimating the benefits or
CPR,7, 20 not considering the prognosis of the
illness,18 and the frequent delegation to
junior staff.21 The role of the doctor’s
faith and ethnicity is also relevant.22
Appropriately timed end-of-life discussions require robust
prognostic information. Some have argued that attention to prognosis has
declined as our ability to diagnose and treat disease has
increased.23 Further, our estimates of
prognosis are not always accurate nor communicated to
patients.15
Evidence is strongly in favour of patients themselves
wishing to discuss prognosis,24 although this
is not a universal finding.25 However, typical
illness trajectories can inform decisions about when to discuss end-of-life care
and therefore permit a more gradual and considered transition to a palliative
approach.26 This study further demonstrates
that simple prognostic markers in a common illness can indicate high mortality,
and hence the appropriateness of advanced care planning.
This is a complex situation, given the sensitivity of the
issues, the prognostic uncertainty, and the involvement of staff with different
levels of clinical and communication skill working under often considerable time
pressure.
However, when faced with a possible life-threatening
decline, it remains a worthwhile goal that patients and their families would be
included in sensitively conducted and well informed discussions in which the
patient’s wishes were articulated and subsequently respected. Frameworks
for such interventions have been developed,19,
27 and evidence supporting their benefit to patients and their families
reported.5
This study is limited by its retrospective and single centre
nature, and also by documentation that does not always reflect the content of
discussions with patients and families.
ConclusionsCAP carries with it associated significant mortality. Age
>80 and illness severity identify patients at over 50% risk of 12-month
mortality. Discussions about end-of-life care are in the minority, even in these
groups at high risk of death. Currently, resuscitation status appears to serve
more as a surrogate marker for a dying patient, rather than a means of
ascertaining at-risk patients’ wishes in the event of terminal illness.
This represents a missed opportunity to ascertain and value patient’s
preferences for end-of-life care.
Further research is warranted into the barriers to
discussions about end-of-life care, and initiatives to better facilitate and
frame these discussions..
Competing interests: None
declared.
Ethics approval: The Multi-region
Ethics Committee confirmed ethical approval was not required for the
observational study from which this data was subsequently drawn as a sub-group
analysis.
Author information: David G Tripp,
General Medical and Intensive Care Registrar, Capital and Coast District Health
Board, Wellington, New Zealand
Acknowledgements: Jonathan Adler,
Palliative Medicine Physician; Kyle Perrin, Respiratory Physician; Robyn
Toomath, Clinical Director, General Medicine; Paula Peacock, Sandra Allmark and
Peter Walsh, Decision Support Unit; Capital and Coast District Health Board,
Wellington
Correspondence: David Tripp. Email: David.Tripp@xtra.co.nz
References:
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