Reversals in Decisions about Life-Sustaining Treatment and Associated Factors among Older Patients with Terminal Stage of Cardiopulmonary Disease

Jung-Ja Choi; Su Hyun Kim; Shin-Woo Kim

doi:10.4040/jkan.2019.49.3.329

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Choi, Kim, and Kim: Reversals in Decisions about Life-Sustaining Treatment and Associated Factors among Older Patients with Terminal Stage of Cardiopulmonary Disease

Original Article

J Korean Acad Nurs 2019;49(3):329-339.

Published online: 15 January 2019

DOI: https://doi.org/10.4040/jkan.2019.49.3.329

Reversals in Decisions about Life-Sustaining Treatment and Associated Factors among Older Patients with Terminal Stage of Cardiopulmonary Disease

Jung-Ja Choi¹, Su Hyun Kim^1,, Shin-Woo Kim²

¹College of Nursing, Kyungpook National University, Daegu

²Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea

Address reprint requests to : Kim, Su Hyun College of Nursing, Research Institute of Nursing Science, Kyungpook National University, 680 Gukchaebosang-ro, Daegu 41944, Korea Tel: +82-53-420-4928 Fax: +82-53-421-2758 E-mail: suhyun_kim@knu.ac.kr

Received 17 January 2019 Revised 2 May 2019 Accepted 8 May 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

Abstract

Purpose

The purpose of this study was to investigate the frequency, patterns, and factors of reversals in decisions about life-sustaining treatment (LST) among older patients with terminal-stage chronic cardiopulmonary disease.

Methods

This was a retrospective correlational descriptive study based on medical chart review. De-identified patient electronic medical record data were collected from 124 deceased older patients with terminal-stage cardiopulmonary disease who had made reversals of LST decisions in an academic tertiary hospital in 2015. Data were extracted about the reversed LST decisions, LST treatments applied before death, and patients’ demographic and clinical factors. Multivariate logistic regression analysis was used to identify the factors associated with the reversal to higher intensity of LST treatment.

Results

The use of inotropic agents was the most frequently reversed LST treatment, followed by cardiopulmonary resuscitation, intubation, ventilator therapy, and hemodialysis. Inconsistency between the last LST decisions and actual treatments occurred most often in hemodialysis. One-third of the reversals in LST decisions were made toward higher intensity of LST treatment. Patients who had lung diseases (vs. heart diseases); were single, divorced, or bereaved (vs. married); and had an acquaintance as a primary decision maker (vs. the patients themselves) were significantly more likely to reverse the LST decisions to higher intensity of LST treatment.

Conclusion

This study demonstrated the complex and turmoil situation of the LST decision-making process among older patients with terminal-stage cardiopulmonary disease and suggests the importance of support for patients and families in their LST decision-making process.

Keywords: Aged, Cardiopulmonary Resuscitation, Decision Making, Life Support Care, Terminal Care

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Figure 1.

Flowchart of study population.

Figure 2.

Reversals of life-sustaining treatment decisions and administered treatment before death. Numbers show n and % of the decisions and administrations of the treatments.

Figure 3.

Reversal of code status and administered treatments. Numbers show n (%) of the decisions and administrations of the treatments; ^†Reversal to higher intensity of life-sustaining treatment.

Table 1.

Characteristics of Participants and Comparisons between Reversals of Decisions to Higher and Reversals of Decisions to Equal or Lower Intensity of Life-Sustaining Treatment (N=124)

Variables	Total	Reversal to higher intensity of EOL treatment		χ² or t (p value)
		Yes (n=39)	No (n=85)
		N (%)/M±SD
Age (yr)	75.16±7.42	77.13 (8.06)	74.26 (6.98)	2.02 (.045)
Gender
Male	56 (45.2)	22 (56.4)	34 (40.0)	2.91 (.088)
Female	68 (54.8)	17 (43.6)	51 (60.0)
Primary illness
Pulmonary disease	81 (65.3)	19 (48.7)	24 (28.2)	4.95 (.026)
Cardiac disease	43 (34.7)	20 (51.3)	61 (71.8)
Marital status
Married	73 (58.9)	17 (43.6)	56 (65.9)	5.49 (.019)
Single, divorced, or bereaved	51 (41.1)	22 (56.4)	29 (34.1)
Education level
Less than elementary school	63 (50.8)	21 (53.9)	42 (49.4)	6.16 (.104)
Middle school	33 (26.6)	14 (35.9)	19 (22.4)
High school	19 (15.3)	2 (5.1)	17 (20.0)
College or more	9 (7.3)	2 (5.1)	7 (8.2)
Chief complaint
Dyspnea	53 (42.7)	15 (38.5)	38 (44.7)	4.37 (.627)
General weakness	16 (12.9)	5 (12.8)	11 (12.9)
Collapse	13 (10.5)	4 (10.3)	9 (10.6)
High fever	12 (9.7)	5 (12.8)	7 (8.3)
Mental change	7 (5.7)	4 (10.2)	3 (3.5)
Hypotension	3 (2.4)	0 (0.0)	3 (3.5)
Others	20 (16.1)	6 (15.4)	14 (16.5)
LST usage at initial baseline^†
Inotropic drugs	56 (45.2)	25 (64.1)	31 (46.5)	8.24 (.004)
CPR	29 (23.4)	11 (28.2)	18 (21.2)	0.74 (.391)
Airway intubation	26 (21.0)	6 (15.4)	20 (23.5)	1.07 (.301)
Hemodialysis	14 (11.3)	2 (5.1)	12 (14.1)	2.16 (.142)
Ventilator therapy	13 (10.5)	3 (7.7)	10 (11.8)	0.47 (.492)
ECOG at LST decision making
Grade 2	10 (8.0)	1 (2.6)	9 (10.6)	2.48 (.289)
Grade 3	57 (46.0)	18 (46.1)	39 (45.9)
Grade 4	57 (46.0)	20 (51.3)	37 (43.5)
Orientation status
Yes	54 (43.5)	22 (56.4)	32 (37.6)	3.83 (.050)
No	70 (56.5)	17 (43.6)	53 (62.4)
Primary decision maker
Spouse	17 (13.7)	4 (10.3)	13 (15.3)	14.61 (.002)
Offspring	90 (72.6)	25 (64.1)	65 (76.4)
Acquaintance	11 (8.9)	9 (23.0)	2 (2.4)
Patients	6 (4.8)	1 (2.6)	5 (5.9)
Elapsed time for decisions (days)
From admission to 1^st decision	5.08 (5.97)	4.39 (5.08)	5.40 (6.35)	0.88 (.382)
From 1^st decision to reversal	5.08 (6.29)	5.54 (6.12)	4,87 (6.41)	-0.55 (.586)
From reversal to death	8.25 (8.26)	6.62 (8.19)	9.00 (8.24)	1.50 (.140)
From 1^st decision to death	13.33 (10.26)	12.15 (10.62)	13.87 (10.03)	0.87 (.387)

CPR=Cardiopulmonary resuscitation; ECOG=Eastern Cooperative Oncology Group; EOL=End-of-life; LST=Life-sustaining treatment; M=Mean; SD=Standard deviation.

^† Multiple answer.

Table 2.

Multivariate Logistic Regression Analysis on the Factors Associated with Reversals of Decisions to Higher Intensity of Life-Sustaining Treatment

Variables	Beta (SE)	Adjusted OR (95% CI)
Patients’ characteristics
Age	-0.02 (0.04)	0.99 (0.91~1.07)
Gender, male (vs. female)	0.78 (0.53)	2.19 (0.77~6.15)
Education
Less than elementary school	0.63 (1.22)	1.87 (0.17~20.39)
Middle school	1.38 (1.19)	3.97 (0.39~40.94)
High school (vs. college or more)	-0.83 (1.35)	0.54 (0.03~6.17)
Marital status, married (vs. single, divorced, or bereaved)	-1.27 (0.56)	0.28 (0.09~0.84)*
Orientation status, yes (vs. no)	-0.64 (0.52)	0.53 (0.19~1.44)
Primary illness, cardiac diseases (vs. pulmonary diseases)	-1.17 (0.53)	0.31 (0.11~0.88)*
Usage of inotropic drugs at initial baseline	-0.21 (0.54)	0.81 (0.28~2.31)
Primary decision makers
Spouses	0.97 (1.42)	2.63 (0.16~42.44)
Offspring	0.95 (1.30)	2.60 (0.20~33.37)
Acquaintance (vs. patients)	3.40 (1.58)	29.97 (1.35~665.44)*

SE=standard error; Adjusted OR=adjusted odds ratio; 95% CI=95% confidence interval.

^* p<.05.

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