End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis

Cook, Ifor; Kirkup, Aimee L; Langham, Lauren J; Malik, Muminah A; Marlow, Gabriella; Sammy, Ian

doi:10.1177/2333721417713422

Cited by 41 publications

(36 citation statements)

References 51 publications

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“…2,3 It has been found that age increases the use of "do not resuscitate" orders, but it is unclear from the literature whether using age to make these decisions represents "ageism". 21 One of the important points that emerge from our results is that patients with dementia living in nursing homes came in ED to die. One hypothesis is that there are few advance directives as found in a previous study 14 and no anticipation about end-of-life decision before admission in ED.…”

Section: Discussionmentioning

confidence: 82%

“…Concerning reasons for making decisions of withholding or withdrawing life‐sustaining treatments, we found that previous functional limitation and age were the most frequent criteria to justify limiting life‐support therapies, whereas previous studies found that acute medical disorder was the principal criteria . It has been found that age increases the use of “do not resuscitate” orders, but it is unclear from the literature whether using age to make these decisions represents “ageism” …”

Section: Discussionmentioning

confidence: 99%

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Difficulty of the decision‐making process in emergency departments for end‐of‐life patients

Douplat

Berthiller

Schott

et al. 2019

Evaluation Clinical Practice

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Background In emergency departments, for some patients, death is preceded by a decision of withholding or withdrawing life‐sustaining treatments. This concerns mainly patients over 80, with many comorbidities. The decision‐making process of these decisions in emergency departments has not been extensively studied, especially for noncommunicating patients. Aim The purpose of this study is to describe the decision‐making process of withholding and withdrawing life‐sustaining treatments in emergency departments for noncommunicating patients and the outcome of said patients. Design We conducted a prospective multicenter study in three emergency departments of university hospitals from September 2015 to January 2017. Results We included 109 patients in the study. Fifty‐eight (53.2%) patients were coming from nursing homes and 52 (47.7%) patients had dementia. Decisions of withholding life‐sustaining treatment concerned 93 patients (85.3%) and were more frequent when a surrogate decision maker was present 61 (65.6%) versus seven (43.8%) patients. The most relevant factors that lead to these decisions were previous functional limitation (71.6%) and age (69.7%). Decision was taken by two physicians for 80 patients (73.4%). The nursing staff and general practitioner were, respectively, involved in 31 (28.4%) and two (1.8%) patients. A majority of the patients had no advance directives (89.9%), and the relatives were implicated in the decision‐making process for 96 patients (88.1%). Death in emergency departments occurred for 47 patients (43.1%), and after 21 days, 84 patients (77.1 %) died. Conclusion There is little anticipation in end‐of‐life decisions. Discussion with patients concerning their end‐of‐life wishes and the writing of advance directives, especially for patients with chronic diseases, must be encouraged early.

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Section: Discussionmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Difficulty of the decision‐making process in emergency departments for end‐of‐life patients

Douplat

Berthiller

Schott

et al. 2019

Evaluation Clinical Practice

View full text Add to dashboard Cite

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“…[14] Tier 1 includes peoples' preferences for end-of-life care; choosing a place of death helps people to die at home, whereas people whose preference is unknown are more likely to be admitted to hospital for end-of-life care. [15] Lower proportions of the Asian participants in this study compared with westerners had expressed a preferred place of death or signed Do Not Resuscitate agreements, [16] which highlights an unmet need for advocacy to better prepare elderly Taiwanese people for death. The prevalence of frailty was similar to other reports.…”

Section: Discussionmentioning

confidence: 83%

First Insights on Value-Based Healthcare of Elders Using ICHOM Older Person Standard Set Reporting

Lee

Peng

Lin

et al. 2019

Preprint

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Background: Clinical guidelines for specific conditions fragment care provision for elders. The International Consortium for Health Outcomes Measurement (ICHOM) has developed a global standard set of outcome measures for comprehensive assessment of older persons. The goal of this study was to report value-based health metrics in Taiwan using this ICHOM toolset. Methods: The cross-sectional study of baseline data excerpted from a prospective longitudinal cohort, which recruited people ≥65 years old with ≥3 chronic medical conditions who received value-based healthcare services between July and December 2018. All participants received measurements of physical performance, anthropometric characteristics, health-related behaviors, Charlson Comorbidity Index, and Montreal Cognitive Assessment. The ICHOM toolset comprises three tiers: 1 includes frailty and having chosen a preferred place of death; 2 includes polypharmacy, falls, and participation in decision-making; and 3 includes loneliness, activities of daily living, pain, depression, and walking speed. These items were converted into a 0–10 point value-based healthcare score, with high value-based health status defined as ≥8/10 points. Results: Frequencies of individual ICHOM indicators were: frail 11.7%, chose preferred place of death 14.4%, polypharmacy 31.5%, fell 17.1%, participated in decision-making 81.6%, loneliness 26.8%, limited activities of daily living 22.4, pain 10.4%, depressed mood 13.0%, and slowness 38.5%. People with high disease severity (OR 0.40, 95% CI 0.21–0.76, p=0.005) or cognitive impairment (OR 0.49, 95%CI 0.27–0.87, p=0.014) were less likely to have high value-based healthcare status. Conclusions: The ICHOM Standard Set Older Person health outcome measures provide an opportunity to shift from a disease-centric medical paradigm to patient-focused goals. This study identified advanced age, chronic disease and cognitive impairment as important barriers to achieving high value-based healthcare status.

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“…an agreement between a patient and a health care professional not to attempt cardiopulmonary resuscitation in case of cardiac arrest. Since a DNR status is more often agreed upon by patients with higher age, 28 we assumed higher probabilities for higher aged patients. We assumed that for patients who suffered cardiac arrest with a DNR status, no CPR would be attempted and death is certain.…”

Section: Decision Treementioning

confidence: 99%

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation after in-hospital cardiac arrest: A Markov decision model

et al. 2019

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Background: This study aimed to estimate the cost-effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest treatment.Methods: A decision tree and Markov model were constructed based on current literature. The model was conditional on age, Charlson Comorbidity Index (CCI) and sex. Three treatment strategies were considered: ECPR for patients with an Age-Combined Charlson Comorbidity Index (ACCI) below different thresholds (2-4), ECPR for everyone (EALL), and ECPR for no one (NE). Cost-effectiveness was assessed with costs per quality-of-life adjusted life years (QALY). Measurements and main results: Treating eligible patients with an ACCI below 2 points costs 8394 (95% CI: 4922-14,911) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 3 costs 8825 (95% CI: 5192-15,777) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 4 costs 9311 (95% CI: 5478-16,690) euro per extra QALY per IHCA patient; treating every eligible patient with ECPR costs 10,818 (95% CI: 6357-19,400) euro per extra QALY per IHCA patient.For WTP thresholds of 0-9500 euro, NE has the highest probability of being the most cost-effective strategy. For WTP thresholds between 9500 and 12,500, treating eligible patients with an ACCI below 4 has the highest probability of being the most cost-effective strategy. For WTP thresholds of 12,500 or higher, EALL was found to have the highest probability of being the most costeffective strategy. Conclusions:Given that conventional WTP thresholds in Europe and North-America lie between 50,000-100,000 euro or U.S. dollars, ECPR can be considered a cost-effective treatment after in-hospital cardiac arrest from a healthcare perspective. More research is necessary to validate the effectiveness of ECPR, with a focus on the long-term effects of complications of ECPR.

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End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis

Cited by 41 publications

References 51 publications

Difficulty of the decision‐making process in emergency departments for end‐of‐life patients

Difficulty of the decision‐making process in emergency departments for end‐of‐life patients

First Insights on Value-Based Healthcare of Elders Using ICHOM Older Person Standard Set Reporting

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation after in-hospital cardiac arrest: A Markov decision model

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