Learning to Discuss Resuscitation Preferences: As Important as Learning to Resuscitate?

This July, all new residents in training became certified in basic life support (BLS) and advance cardiac life support (ACLS). The training is a full day and rigorous—to be certified, the resident needs to demonstrate competence. Data suggest that this training, as well as improvements in ACLS protocols, led to improvements in survival after an in-hospital arrest. ¹ There is a related procedure, however, that gets little attention—talking to patients regarding the appropriateness of undergoing BLS/ACLS. Competently done, this conversation is associated with reduced patient distress, a better quality of life, and goal-concordant care near the end of life. ² We think as much attention should be focused on teaching residents how to talk about resuscitation attempts as we spend teaching them how to perform BLS/ACLS. ³

In our hospitals, clinicians are required to talk to every patient about whether to perform BLS/ACLS (the code status conversation). ³ Despite the ubiquitous nature of these discussions, there is no required training or certification of competence. In fact, in most hospitals, this task falls to the most junior clinicians. ⁴ At Dartmouth-Hitchcock Medical Center (DHMC), ∼80% of the code status orders are entered by residents in training. Nationally, 40% to 80% of residents report little instruction in end-of-life conversations and one-third have never gotten feedback on their competency.^4–6 Given this, it is not surprising that the quality of these resuscitation conversations is poor and has not changed over the past 15 years. ⁷ Residents focus on whether the patient “wants” resuscitation, and few include a discussion of what the patient is hoping for or the quality of life they would find unacceptable.^8,9

As a resident, M.T.V clearly remembers his own early code status conversation attempts. He was caring for a man with severe emphysema admitted to the hospital for respiratory failure. Despite a progressive decline and poor quality of life, the patient opted to undergo BLS/ACLS protocol. On hospital day 3, he arrested, was intubated, and went to the intensive care unit. The next day, the intensive care team informed M.T.V that the patient's family was upset he had been put on life support—they knew he would not want treatment only to survive in a weaker and sicker state—which M.T.V. had not elicited or shared. The family decided to withdraw life support that day.

This is an important discussion to get right. Many patients living with chronic and serious illnesses do not want to undergo cardiopulmonary resuscitation at the time of their death. ¹⁰ Up to 30% of hospitalized patients with one of nine serious illnesses wanted to avoid BLS/ACLS, but only 50% of treating clinicians knew those preferences. ¹¹ Subjecting patients to resuscitation and life support that is not aligned with their values and goals is a correctable medical error.^12,13 Second, poor quality discussions lead to an inappropriate use of limited resources. For example, up to 40% of the end-of-life cost variation for Medicare cancer patients is due to use of intensive care services. ¹⁴ Third, additional patient and family suffering may occur after cardiopulmonary resuscitation. Bereaved family members have an increased risk of post-traumatic stress disorder (PTSD), and cardiopulmonary resuscitation (CPR) survivors are at increased risk of cognitive and functional disability as well as psychological adjustment disorder (anxiety, depression, and PTSD).^15,16 Finally, clinicians often have moral distress after resuscitative efforts. Approximately one-quarter of residents report symptoms of PTSD due to attempts at resuscitation, which they say adversely affects their work performance. ¹⁷

The good news is that we know how to train residents to have better conversations. Over the past 25 years, educators have defined the key components of this conversation, such as informing the patient about the estimated outcomes of the BLS/ACLS protocol given their medical situation, assessing patient's values and goals, and making a recommendation based on those values. Evidence-based training programs have been developed that lead to better conversations.^18–20 For example, trained residents are more likely to explore patient values and goals, and make a recommendation and less likely to frame the decision as a context-free option. ²¹ Students who have received a formal curriculum and teaching on this topic are among the most confident in their skills. ²² There are no consensus-based training programs specific to BLS/ACLS conversations with patients or families.

Many institutions have started to do better by training all residents to have a best practice conversation. For example, DHMC utilizes a national half-day training in communication, two simulated patient encounters with feedback to the resident, and clinical immersion with our palliative care inpatient team for all internal medicine residents. The impact of the training is obvious. Recently, M.T.V. was the supervising physician for a resident who was talking with a 55-year-old man patient suffering from refractory heart failure. The resident elicited that the patient's functional status was progressively worsening—he was nearly bedbound now. When asked what a minimally acceptable quality of life looked like, he was clear—being able to return home, sit on his porch, and drink a hot cup of coffee. He did not want to go through things that would not accomplish this goal and did not like being in the hospital. The resident shared that if his heart stopped, we were worried it was unlikely to start back up or that he would get home. He recommended that if the goal was to get more time at home with family, we should work on home discharge in the next day with home hospice services. The patient soberly agreed to this plan, thanking the resident for the guidance. The patient's cardiologist informed the resident three days later that the patient had gotten home, was able to sit on his porch with a hot cup of coffee, and enjoy time with his family before he died. This patient was a near miss—without our resident's skillful conversation, he would have missed the opportunity to die at home.

Since the 1970s and 1980s, there has been a broad push to train professionals in BLS/ACLS. This effort has been coordinated nationally by the American Heart Association (AHA) that develops, implements, and modifies the training over time, assuring every physician is getting the same quality training no matter where they practice. ²³ Isn't it time that every clinician has the skills to talk with patients and families about whether BLS/ACLS is consistent with their goals?

We need a national skills-based best practice communication training program that allows residents to learn through individualized feedback during simulated practice. Integrating the training within the AHA's certification and implementation framework would send a strong message about the conversation's importance. We urge the AHA to lead an expert committee to develop guidelines for conversations about BLS/ACLS and build on existing evidence-based methods to teach others to have these conversations. The developed content and certification process should be added to the other resources the AHA offers at (https://cpr.heart.org/en/resources). Standardizing the conversation for BLS/ACLS would allow continued study and improvement of the conversations (in the same way as been done for specific components of ACLS). That way we can ensure that conversations about the appropriateness of BLS/ACLS are of the same quality as the BLS/ACLS that we provide.