Identification of a potentially avoidable cardiopulmonary resuscitation in hematology and oncology wards

In-hospital cardiopulmonary arrest is one of the most undesirable events in caring for patients. Cancer patient is one of the largest in-hospital cardiopulmonary arrest groups. However, most of them do not experience the return of systemic circulation (ROSC) after a cardiopulmonary resuscitation (CPR). Even among those who achieved ROSC, only few are discharged from hospital. In one study, 16 of 73 cancer patients (22%) who had sudden, unanticipated cardiac arrest survived to be discharged from a hospital, but none (0 of 171) of patients who experienced an anticipated cardiac arrest survived [1]. Another meta-analysis revealed that the overall survival to discharge rate in cancer patients was only 6.2% [2]. In the view of these studies, a CPR seems to be less meaningful to resuscitate cancer patients [3]. Furthermore, aggressiveness of cancer care techniques near the end of life, such as a CPR, can deteriorate patients’ quality of life and increase costs related to care [4, 5]. Recently, patients who underwent an early palliative care including advanced care planning for do-not-resuscitate (DNR) showed an improved survival outcome compared with those who experienced a standard care [6].

Clinical outcomes in general CPR population have been improved through advanced knowledge including basic CPR before defibrillation, the use of automated external defibrillators with easy access, new resuscitation algorithms including cardiac compression rates, ventilation rates and volumes, and hypothermia therapy [7‐9]. End-of-life and advanced care planning also may have contributed to improved outcomes of a CPR in the general population by allowing terminally ill patients to choose a DNR, which were effectively decreasing the number of patients that would have worse outcomes [10]. In metastatic cancer patients, it was reported that overall survival to discharge has been improved from 5.6 to 7.8% in recent years, reflecting more selective use of a CPR in cancer patients, with the sickest patients deselected [2]. Through a focus on palliative care for cancer patients and an incorporation of patient goals of care in deciding therapeutic interventions, CPR might be applied more selectively, resulting in higher rates of ROSC and longer survival after CPR. Therefore, selecting out patients who are likely to have the worst prognosis before CPR and excluding them from using a CPR should ultimately improve the total outcome. The identification of a potentially avoidable CPR is an important issue in the palliative care of the cancer.

In this study, we tried to identify the incidence and characteristics of a potentially avoidable CPR in cancer patients who were hospitalized in hematology and oncology wards by using a consensus-driven peer review process. We also sought to evaluate ways in which a potentially avoidable CPR could not be conducted.

In this present study, 137 patients (1.1%) of all hospitalized patients during the study period received a CPR. Among these 137 patients, a potentially avoidable CPR was identified in 37.2% patients. A potentially avoidable CPR was associated with certain cancer types and clinical settings at the time with a CPR. Physicians should pay more attention to these patients to prevent a potentially avoidable CPR.

In the present study, 66 patients (48.2%) achieved ROSC and 12 (8.8%) patients survived through to discharge. These results is in accordance with a previous meta-analysis report of 1707 cancer patients with a CPR, in which ROSC was 45.4 and 12.6% of ROSC was alive to hospital discharge [2]. Furthermore, in the present study, patients with a potentially avoidable CPR showed much worse prognosis than those with a CPR that was not avoidable (ROSC: 39.2% vs. 53.5%, respectively; overall alive to discharge: 2.0% vs. 12.8%, respectively). Even one patient who survived to discharge in a potentially avoidable CPR died within 1 day after discharge. These findings are also similar to the previous study, in which 22% patients who had sudden, unanticipated cardiac arrest survived to be discharged from the hospital, but none of the patients who experienced an anticipated cardiac arrest survived [1]. Therefore, it is important to identify a potentially avoidable CPR to effectively apply a CPR and improve the outcomes of a CPR in cancer patients.

A potentially avoidable CPR was identified according to chemotherapy setting, disease status and clinical situation at the time when cardiopulmonary arrest occurred in the present study. Considering different outcomes of a CPR between patients with a potentially avoidable CPR and those with a CPR that was not avoidable, the identification of a potentially avoidable CPR using these conditions may be useful and valuable to decide whether to apply a CPR or not in the clinical practice. In a potentially avoidable CPR, most causes of cardiopulmonary arrest were irreversible cancer progression related. In contrast, the causes leading to a CPR that was not avoidable were treatment-related or reversible cancer-related symptoms such as cancer bleeding and infection. The reversibility of causes was the most important factor in a classification of a potentially avoidable CPR and a CPR that was not avoidable. In a multivariate analysis, certain cancer types such as lung cancer and lymphoma were a risk factor for potentially avoidable CPR. These findings were not fully explained, but could be attributed to more aggressiveness of physician for cancer treatment until terminal status due to many treatment options and long disease course in these cancer types.

In 29 patients (56.9%) of patients with a potentially avoidable CPR, there was no documented discussion of a CPR or DNR. The other patients who underwent a potentially avoidable CPR did not fully discuss these items before events occurred. Recently, early palliative care, including advanced care planning, has been shown to lead to better survival and quality of life in palliative cancer patients [6]. Perception of patients and their family members for diagnosis and prognosis is significantly associated with patients’ resuscitation preferences [11‐13]. Therefore, the first step to decrease a potentially avoidable CPR should be to discuss disease status and advanced care planning with patients or their family members before the cardiopulmonary arrest event. In fact, there had been little discussion about DNR and hospice care due to prevailing social moods in Korea [14, 15]. However, this social mood has been changed in the past 10 years, and nowadays many patients talk to their doctors to make a decision about their care [16]. In this study, the number of potentially avoidable CPR had an increasing trend until 2011. The events happened the most frequently by 9 cases in 2011. Six cases occurred in each 2006, 2007, 2009, and 2010. There were 5 cases in 2004, 2 in 2008, and 1 in 2005. However, the Korean Ministry of Health and Welfare with government started discussing this social issue in 2012. The number of events got decreased from 2012 of 4 cases, and there was one case in 2013. Seoul National University Bundang Hospital set up a new department for palliative care and started inpatient and outpatient service in 2015. It helped medical providers to prevent unwanted arrest events in hospital. As a result, there was only one case in 2015.

As results, the cases of a potentially avoidable CPR could have decreased, but some families still want resuscitation despite its irreversibility. The more time and the information about a disease course should be provided to these patients and their family members [17, 18]. As one of tools to provide more information and enlighten patients and their family members for a CPR decision making, video decision support tool has been suggested. In a randomized controlled trial, patients with a 3 min video for describing CPR and the chance of CPR success had better CPR knowledge and were more likely to choose DNR compared with a verbal narrative group [19].

Our study had some limitations. First, we reviewed medical records retrospectively, and it was possible that these records did not reflect the patients’ situation accurately and objectively. Second, other physician could have different perspectives to determine a potentially avoidable CPR from this study. In this study, two independent physicians were incorporated to identify a potentially avoidable CPR. If there was any discrepancy between two physicians, we tried to objectively determine it through consensus-driven discussion. Third, in terms of survivors after CPR, quality of life is an important issue. However, we followed just survival and analysed it. We did not address quality of life for survivors. Finally, because we only studied localized, in-hospital CPR, patients without-hospital cardiopulmonary arrest were excluded.

In conclusion, of total CPR cases with cancer, a potentially avoidable CPR was identified in 37.2% patients. A potentially avoidable CPR frequently occurred in advanced diseases and certain tumor types, such as lung cancer and lymphoma. This information should be used to prevent a potentially avoidable CPR. Furthermore, cancer patients who received a potentially avoidable CPR showed worse outcomes. Therefore, an effort to identify a potentially avoidable CPR should be needed to effectively apply a CPR and improve outcomes of a CPR in cancer patients.