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Communicating End-of-Life Decisions
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
TO THE EDITOR:
Hofmann and colleagues [1] observed that in their experience “a majority of seriously ill inpatients had not discussed and were not interested in discussing preferences for cardiopulmonary resuscitation (58%) …” and contrasted their results with ours (only 19% of our patients could be so categorized) [2]. Because the authors do not discuss possible reasons for these differences, I would like to propose a few.
First, I believe that the authors have incorrectly summarized their own findings. Among their 1589 respondents, 366 (23%) had previously discussed cardiopulmonary resuscitation preferences and another 516 (32%) hadn't but wanted to. Thus, the remaining 707 (44%, not 58%) of their patients “had not discussed and were not interested in discussing cardiopulmonary resuscitation.”
Second, in both studies, a similar proportion of patients who had not discussed cardiopulmonary resuscitation reported that they did not want to (34% in our study and 32% in Hofmann and colleagues' study). Almost the entire difference between the studies' respective findings can be explained by the fact that twice as many of our patients did discuss cardiopulmonary resuscitation (47% compared with 23%), the principal outcome of interest. This is not surprising when one considers that all of our patients were exposed to a series of successful interventions designed to achieve that outcome [3], whereas Hofmann and colleagues' patients included the control group from SUPPORT's (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) unsuccessful phase II intervention trial [4].
Finally, we studied consecutive series of patients admitted to a community hospital (in-hospital mortality rate, 6.4%) whose personal physicians were encouraged to engage them in discussions about end-of-life care. Hofmann and colleagues reported results from 38% (1832 of 4804) of patients with selected diagnoses (in-hospital mortality rate, 4.4%) admitted to five different tertiary care hospitals who were asked a series of study questions by trained interviewers, apparently without any participation by the patients' personal physicians.
I agree with the authors' conclusion that “communication about preferences for cardiopulmonary resuscitation is uncommon” among hospitalized adults. Further studies are needed to corroborate their much more troubling conclusion that “a majority of patients who have not discussed preferences for end-of-life care do not want to do so.” In my view, it all depends on who asks, how and why they ask, and how well they “support” the patient in the process.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
