Terminally ill cancer patients who watched either of two videos about the
option to forego resuscitation overwhelmingly elected that route for the patient
in the video, if not for themselves, according to a new study.
But the vignettes - whose only difference was whether fictional patients
decided on their own to skip cardiopulmonary resuscitation (CPR) or got a
recommendation from their doctor - elicited high marks from real patients for
the video doctors' compassion in discussing a difficult subject.
Importantly, study participants didn't think less of a doctor who recommended
that patients forgo life-saving efforts during cardiac arrest.
"The reassuring finding here is that both approaches (doctor- versus
patient-guided decisions about whether to be resuscitated) are likely to reach
very similar results," said study author Dr Eduardo Bruera, department chair of
palliative care and rehabilitation medicine in the cancer medicine division at
the University of Texas MD Anderson Cancer Center in Houston.
Dying cancer patients can survive cardiac arrest if given CPR, but experts
note that most of those patients will suffer from serious complications and
typically die within days to weeks.
The alternative is for a patient to request in advance not to be resuscitated
in a crisis. However, experts find that most cancer patients do not have
conversations with their doctors about whether they want CPR in an
Bruera and his colleagues wanted to test approaches to such conversations and
see whether patients would rather be advised what to do or to make up their own
minds after hearing the information.
How the study was done
In the study, 78 patients with advanced cancer at MD Anderson watched two
videos depicting a middle-aged doctor telling a woman in her 60s with cancer
about resuscitation options.
In one video, the doctor recommended a do-not-resuscitate option, whereas in
a nearly identical video, the doctor asked whether the patient wanted to opt out
All 30 study patients who had already requested do-not-resuscitate orders for
themselves chose the same for the patient depicted in the video. Among the 48
patients who hadn't made any CPR decisions, 30 chose the option for the patient
in the video.
Factors such as age, gender or socioeconomic status were not linked to
patients' do-not-resuscitate decisions, researchers found.
Only three patients had had a conversation about resuscitation with their
doctors, according to the report that appears in the journal Cancer.
"Patients might be willing to make that decision for themselves if the
conversation occurs, they just haven't had the conversation with their doctors
yet," Bruera said.
Researchers have already tested videos in clinics as a way to inform patients
about the realities of CPR and reduce patient requests for it.
"The use of video technology rather than simply a conversation or giving
people a piece of paper might provide patients with access to information in a
much more effective way," Bruera said.
"The potential is for videos to be an educational tool before having a
For time-strapped doctors, having the sensitive talk about end-of-life
options is difficult and doctors frequently cite their fear that the
conversation will make them appear uncompassionate to patients, experts
But the high compassion scores patients in the study gave to the video
doctors could be seen as a sign of appreciation for the conversation taking
place in any form, wrote Rebecca Pentz and Anne Lederman Flamm of Emory
University School of Medicine in Atlanta in an accompanying editorial.
Videos may act as icebreakers, but won't replace the crucial human
interaction, according to Dr Andrew Shuman, head and neck surgical fellow at
Memorial Sloan-Kettering Cancer Center in New York.
"Using visual media to educate and guide end-of-life decision-making may be
quite useful, but in my opinion, will never replace the importance of direct and
open communication between patients and clinicians," said Shuman, who was not
involved in the study.
"Unfortunately, many clinicians are not comfortable addressing end-of-life
decisions with patients due to issues involving lack of training in how to have
these difficult conversations, uncertainties in estimating prognosis, and the
(often erroneous) perception that patients do not want to discuss these issues
either," he said.
Another expert questioned the study's impact on clinical practices since
patients made do-not-resuscitate decisions for another person and not
"Whether (this study) really translates into an action item for healthcare
professionals remains uncertain," said Dr Leonard Lichtenfeld, deputy chief
medical officer for the American Cancer Society.
"There's a bit of a distance between saying what someone else should do
versus how they might respond to their own situation," Lichtenfeld said.