One-quarter of Patients with Severe Congestive Heart Failure Do Not Want To Be Resuscitated, Yale Study Finds/Many Physicians Incorrectly Predict Patients' Preferences

Although resuscitation is often used with patients suffering from severe congestive heart failure, nearly one in four of those patients who were hospitalized said they did not wish to be resuscitated if their hearts stopped beating, according to a study in the Aug. l8 issue of Circulation, the journal of the American Heart Association.

Twenty-three percent of the patients said they did not want to be resuscitated, 69 percent definitely wanted resuscitation and 8 percent were uncertain. The study, conducted between 1989 and 1994, involved 936 patients hospitalized for congestive heart failure. Heart failure is the most frequent cause of hospitalization for people age 65 and older.

Patients who perceived they would live less than two more months were the most likely to reject the prospect of resuscitation, researchers found. Patients who were older, wealthier and less able to take care of their own basic needs in the two weeks before hospitalization also were more likely to reject resuscitation.

The study also documented the preferences of 600 of the 936 patients two months after they left the hospital. At that point, l9 percent of the 600 patients had changed their preferences about resuscitation, including 40 percent (48 of 120 patients) who had earlier rejected resuscitation, researchers discovered.

Harlan M. Krumholz, M.D., a cardiologist at the Yale University School of Medicine and the principal author of the study, said the research underscores the differences in the progression of disease in congestive heart failure as opposed to other terminal illnesses, such as AIDS or cancer. “With other diseases, patients feel sicker and sicker each day as they get closer to death. Congestive heart failure patients may be hospitalized several times, but in between these periods, they often feel much better. This may explain why we see far more patients wanting resuscitation. When their symptoms fade for a while, they are able to regain their hope of surviving.

“It’s also clear from our study that patients do change their minds about resuscitation, so continuing conversations about resuscitation preferences are important, particularly when the patient’s condition is stable and the prognosis is better,” Krumholz said. “Without an ongoing dialogue, physicians will have more difficulty making decisions their patients would want.”

Physicians’ Perceptions of Patient Preferences

Researchers also interviewed physicians of about two-thirds of the 936 patients in the study to monitor how accurately they perceived their patients’ wishes about resuscitation. Results of these interviews showed that 24 percent of physicians held incorrect perceptions.

Physicians most likely to predict their patients’ preferences correctly were those who believed they themselves would not choose resuscitation if they were in that patient’s position. The study found that the older the patient, the more likely his or her physician was to predict that patient’s preference incorrectly. Furthermore, even physicians who had discussed resuscitation preferences with their patients were found to be no more accurate in predicting patients’ wishes than those who had not.

The Circulation article noted that physicians discuss resuscitation issues less frequently with congestive heart failure patients than with other terminally patients. Yet these patients often die suddenly during periods when they appear to be functioning relatively well.

The findings were part of the SUPPORT project, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. SUPPORT is the largest study ever done on dying patients in America, involving almost l0,000 patients at five teaching hospitals over a l0 year period. The project was funded by the Robert Wood Johnson Foundation. Information about this and other research can be found at http://www.lastacts.org.

The study involved researchers from the section of cardiovascular medicine, the department of medicine and the department of epidemiology and public health at the Yale School of Medicine; the Yale-New Haven Hospital Center for Outcomes Research and Evaluation; Beth Israel Hospital, Boston, Mass.; the Center for Gerontology and Health Care Research at Brown University; the UCLA School of Medicine; the Marshfield Medical Research Foundation at the Marshfield Clinic, Wis.; Duke University Medical Center; Case Western Reserve University; George Washington University Medical Center; and the University of California at San Francisco.

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