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Figure 1.
Forest Plot for the Association of Communication Interventions With Patient Preference for Resuscitation in 11 Trials
Forest Plot for the Association of Communication Interventions With Patient Preference for Resuscitation in 11 Trials26-31,35-38,40

The squares and horizontal lines correspond to the study-specific risk ratio (RR) and 95% CI. The diamond represents the pooled RR of overall preference. The vertical dashed line indicates the overall pooled RR of 0.70. CPR indicates cardiopulmonary resuscitation.

Figure 2.
Forest Plot for the Association of Communication Interventions With Patient Knowledge Regarding Measures and Outcome of Resuscitation in 5 Trials
Forest Plot for the Association of Communication Interventions With Patient Knowledge Regarding Measures and Outcome of Resuscitation in 5 Trials26-29,37

The squares and horizontal lines correspond to the study-specific standardized mean difference (SMD) and 95% CI. The diamond represents the pooled SMD of patient knowledge. The vertical dashed line indicates the overall pooled SMD of 0.55.

Table 1.  
Summary of the Included Studies, With Quality Assessed Using the Cochrane Risk of Bias Tool
Summary of the Included Studies, With Quality Assessed Using the Cochrane Risk of Bias Tool
Table 2.  
Overall Results and the Results After Stratification of Meta-analysis
Overall Results and the Results After Stratification of Meta-analysis
1.
Committee on Quality of Health Care in America, Institute of Medicine.  Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
2.
Keyserlingk  EW.  Review of report: Deciding to Forego Life-Sustaining Treatment (President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Washington, DC, March, 1983).  Health Law Can. 1984;4(4):103-107.PubMedGoogle Scholar
3.
Council on Ethical and Judicial Affairs, American Medical Association.  Guidelines for the appropriate use of do-not-resuscitate orders.  JAMA. 1991;265(14):1868-1871. doi:10.1001/jama.1991.03460140096034PubMedGoogle ScholarCrossref
4.
Kass-Bartelmes  BL, Hughes  R.  Advance care planning: preferences for care at the end of life.  J Pain Palliat Care Pharmacother. 2004;18(1):87-109.PubMedGoogle Scholar
5.
Overdyk  FJ, Dowling  O, Marino  J,  et al.  Association of opioids and sedatives with increased risk of in-hospital cardiopulmonary arrest from an administrative database.  PLoS One. 2016;11(2):e0150214. doi:10.1371/journal.pone.0150214PubMedGoogle ScholarCrossref
6.
Marco  CA, Larkin  GL.  Cardiopulmonary resuscitation: knowledge and opinions among the U.S. general public: state of the science-fiction [published correction appears in Resuscitation. 2009;80(3):389].  Resuscitation. 2008;79(3):490-498. doi:10.1016/j.resuscitation.2008.07.013PubMedGoogle ScholarCrossref
7.
Diem  SJ, Lantos  JD, Tulsky  JA.  Cardiopulmonary resuscitation on television: miracles and misinformation.  N Engl J Med. 1996;334(24):1578-1582. doi:10.1056/NEJM199606133342406PubMedGoogle ScholarCrossref
8.
Perkins  GD, Cooke  MW.  Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators.  Emerg Med J. 2012;29(1):3-5. doi:10.1136/emermed-2011-200758PubMedGoogle ScholarCrossref
9.
Meaney  PA, Nadkarni  VM, Kern  KB, Indik  JH, Halperin  HR, Berg  RA.  Rhythms and outcomes of adult in-hospital cardiac arrest.  Crit Care Med. 2010;38(1):101-108. doi:10.1097/CCM.0b013e3181b43282PubMedGoogle ScholarCrossref
10.
Perkins  GD, Temple  RM, George  R.  Time to intervene: lessons from the NCEPOD report.  Resuscitation. 2012;83(11):1305-1306. doi:10.1016/j.resuscitation.2012.08.332PubMedGoogle ScholarCrossref
11.
Tulsky  JA, Chesney  MA, Lo  B.  How do medical residents discuss resuscitation with patients?  J Gen Intern Med. 1995;10(8):436-442. doi:10.1007/BF02599915PubMedGoogle ScholarCrossref
12.
Einstein  DJ, Einstein  KL, Mathew  P.  Dying for advice: code status discussions between resident physicians and patients with advanced cancer: a national survey.  J Palliat Med. 2015;18(6):535-541. doi:10.1089/jpm.2014.0373PubMedGoogle ScholarCrossref
13.
Anderson  WG, Chase  R, Pantilat  SZ, Tulsky  JA, Auerbach  AD.  Code status discussions between attending hospitalist physicians and medical patients at hospital admission.  J Gen Intern Med. 2011;26(4):359-366. doi:10.1007/s11606-010-1568-6PubMedGoogle ScholarCrossref
14.
El-Jawahri  A, Lau-Min  K, Nipp  RD,  et al.  Processes of code status transitions in hospitalized patients with advanced cancer.  Cancer. 2017;123(24):4895-4902. doi:10.1002/cncr.30969PubMedGoogle ScholarCrossref
15.
Tulsky  JA, Fischer  GS, Rose  MR, Arnold  RM.  Opening the black box: how do physicians communicate about advance directives?  Ann Intern Med. 1998;129(6):441-449. doi:10.7326/0003-4819-129-6-199809150-00003PubMedGoogle ScholarCrossref
16.
Covinsky  KE, Fuller  JD, Yaffe  K,  et al.  Communication and decision-making in seriously ill patients: findings of the SUPPORT project: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.  J Am Geriatr Soc. 2000;48(S1)(suppl):S187-S193. doi:10.1111/j.1532-5415.2000.tb03131.xPubMedGoogle ScholarCrossref
17.
Billings  ME, Curtis  JR, Engelberg  RA.  Medicine residents’ self-perceived competence in end-of-life care.  Acad Med. 2009;84(11):1533-1539. doi:10.1097/ACM.0b013e3181bbb490PubMedGoogle ScholarCrossref
18.
Deep  KS, Griffith  CH, Wilson  JF.  Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.  J Gen Intern Med. 2008;23(11):1877-1882. doi:10.1007/s11606-008-0779-6PubMedGoogle ScholarCrossref
19.
Momen  NC, Barclay  SI.  Addressing “the elephant on the table”: barriers to end of life care conversations in heart failure: a literature review and narrative synthesis.  Curr Opin Support Palliat Care. 2011;5(4):312-316. doi:10.1097/SPC.0b013e32834b8c4dPubMedGoogle ScholarCrossref
20.
Knauft  E, Nielsen  EL, Engelberg  RA, Patrick  DL, Curtis  JR.  Barriers and facilitators to end-of-life care communication for patients with COPD.  Chest. 2005;127(6):2188-2196. doi:10.1378/chest.127.6.2188PubMedGoogle ScholarCrossref
21.
Visser  M, Deliens  L, Houttekier  D.  Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review.  Crit Care. 2014;18(6):604. doi:10.1186/s13054-014-0604-zPubMedGoogle ScholarCrossref
22.
Siegrist  V, Eken  C, Nickel  CH, Mata  R, Hertwig  R, Bingisser  R.  End-of-life decisions in emergency patients: prevalence, outcome, and physician effect [published online May 30, 2018].  QJM. doi:10.1093/qjmed/hcy112PubMedGoogle Scholar
23.
Moher  D, Liberati  A, Tetzlaff  J, Altman  DG; PRISMA Group.  Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement [published correction appears in Int J Surg. 2010;8(8):658].  Int J Surg. 2010;8(5):336-341. doi:10.1016/j.ijsu.2010.02.007PubMedGoogle ScholarCrossref
24.
Lefebvre  C, Manheimer  E, Glanville  J. Chapter 6: searching for studies. In: Higgins J, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. West Sussex, England: John Wiley & Sons; 2011:95-150. http://handbook-5-1.cochrane.org/. Updated March 2011. Accessed April 26, 2019.
25.
Higgins  JP, Altman  DG, Gøtzsche  PC,  et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group.  The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.  BMJ. 2011;343:d5928. doi:10.1136/bmj.d5928PubMedGoogle ScholarCrossref
26.
El-Jawahri  A, Mitchell  SL, Paasche-Orlow  MK,  et al.  A randomized controlled trial of a CPR and intubation video decision support tool for hospitalized patients.  J Gen Intern Med. 2015;30(8):1071-1080. doi:10.1007/s11606-015-3200-2PubMedGoogle ScholarCrossref
27.
El-Jawahri  A, Paasche-Orlow  MK, Matlock  D,  et al.  Randomized, controlled trial of an advance care planning video decision support tool for patients with advanced heart failure.  Circulation. 2016;134(1):52-60. doi:10.1161/CIRCULATIONAHA.116.021937PubMedGoogle ScholarCrossref
28.
El-Jawahri  A, Podgurski  LM, Eichler  AF,  et al.  Use of video to facilitate end-of-life discussions with patients with cancer: a randomized controlled trial [published correction appears in J Clin Oncol. 2010;28(8):1438].  J Clin Oncol. 2010;28(2):305-310. doi:10.1200/JCO.2009.24.7502PubMedGoogle ScholarCrossref
29.
Epstein  AS, Volandes  AE, Chen  LY,  et al.  A randomized controlled trial of a cardiopulmonary resuscitation video in advance care planning for progressive pancreas and hepatobiliary cancer patients.  J Palliat Med. 2013;16(6):623-631. doi:10.1089/jpm.2012.0524PubMedGoogle ScholarCrossref
30.
Kirchhoff  KT, Hammes  BJ, Kehl  KA, Briggs  LA, Brown  RL.  Effect of a disease-specific advance care planning intervention on end-of-life care.  J Am Geriatr Soc. 2012;60(5):946-950. doi:10.1111/j.1532-5415.2012.03917.xPubMedGoogle ScholarCrossref
31.
Merino  AM, Greiner  R, Hartwig  K.  A randomized controlled trial of a CPR decision support video for patients admitted to the general medicine service.  J Hosp Med. 2017;12(9):700-704. doi:10.12788/jhm.2791PubMedGoogle ScholarCrossref
32.
Mittal  K, Sharma  K, Dangayach  N,  et al.  Use of a standardized code status explanation by residents among hospitalized patients.  J Community Hosp Intern Med Perspect. 2014;4:4.PubMedGoogle Scholar
33.
Nicolasora  N, Pannala  R, Mountantonakis  S,  et al.  If asked, hospitalized patients will choose whether to receive life-sustaining therapies.  J Hosp Med. 2006;1(3):161-167. doi:10.1002/jhm.78PubMedGoogle ScholarCrossref
34.
Rhondali  W, Perez-Cruz  P, Hui  D,  et al.  Patient-physician communication about code status preferences: a randomized controlled trial.  Cancer. 2013;119(11):2067-2073. doi:10.1002/cncr.27981PubMedGoogle ScholarCrossref
35.
Richardson-Royer  C, Naqvi  I, Riffel  C,  et al.  A video depicting resuscitation did not impact upon patients’ decision-making.  Int J Gen Med. 2018;11:73-77. doi:10.2147/IJGM.S147109PubMedGoogle ScholarCrossref
36.
Stein  RA, Sharpe  L, Bell  ML, Boyle  FM, Dunn  SM, Clarke  SJ.  Randomized controlled trial of a structured intervention to facilitate end-of-life decision making in patients with advanced cancer.  J Clin Oncol. 2013;31(27):3403-3410. doi:10.1200/JCO.2011.40.8872PubMedGoogle ScholarCrossref
37.
Volandes  AE, Brandeis  GH, Davis  AD,  et al.  A randomized controlled trial of a goals-of-care video for elderly patients admitted to skilled nursing facilities.  J Palliat Med. 2012;15(7):805-811. doi:10.1089/jpm.2011.0505PubMedGoogle ScholarCrossref
38.
Volandes  AE, Paasche-Orlow  MK, Mitchell  SL,  et al.  Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer.  J Clin Oncol. 2013;31(3):380-386. doi:10.1200/JCO.2012.43.9570PubMedGoogle ScholarCrossref
39.
Wilson  ME, Krupa  A, Hinds  RF,  et al.  A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial.  Crit Care Med. 2015;43(3):621-629. doi:10.1097/CCM.0000000000000749PubMedGoogle ScholarCrossref
40.
Yamada  R, Galecki  AT, Goold  SD, Hogikyan  RV.  A multimedia intervention on cardiopulmonary resuscitation and advance directives.  J Gen Intern Med. 1999;14(9):559-563. doi:10.1046/j.1525-1497.1999.11208.xPubMedGoogle ScholarCrossref
41.
Kerridge  IH, Pearson  SA, Rolfe  IE, Lowe  M, McPhee  JR.  Impact of written information on knowledge and preferences for cardiopulmonary resuscitation.  Med J Aust. 1999;171(5):239-242. doi:10.5694/j.1326-5377.1999.tb123629.xPubMedGoogle ScholarCrossref
42.
Council on Scientific Affairs, American Medical Association.  Good care of the dying patient.  JAMA. 1996;275(6):474-478. doi:10.1001/jama.1996.03530300058041PubMedGoogle ScholarCrossref
43.
Lo  B, Snyder  L.  Care at the end of life: guiding practice where there are no easy answers.  Ann Intern Med. 1999;130(9):772-774. doi:10.7326/0003-4819-130-9-199905040-00018PubMedGoogle ScholarCrossref
44.
Lynn  J.  Measuring quality of care at the end of life: a statement of principles.  J Am Geriatr Soc. 1997;45(4):526-527. doi:10.1111/j.1532-5415.1997.tb05184.xPubMedGoogle ScholarCrossref
45.
Rocker  G, Cook  D, Sjokvist  P,  et al; Level of Care Study Investigators; Canadian Critical Care Trials Group.  Clinician predictions of intensive care unit mortality.  Crit Care Med. 2004;32(5):1149-1154. doi:10.1097/01.CCM.0000126402.51524.52PubMedGoogle ScholarCrossref
46.
Curtis  JR, Vincent  JL.  Ethics and end-of-life care for adults in the intensive care unit.  Lancet. 2010;376(9749):1347-1353. doi:10.1016/S0140-6736(10)60143-2PubMedGoogle ScholarCrossref
47.
Azoulay  E, Chevret  S, Leleu  G,  et al.  Half the families of intensive care unit patients experience inadequate communication with physicians.  Crit Care Med. 2000;28(8):3044-3049. doi:10.1097/00003246-200008000-00061PubMedGoogle ScholarCrossref
48.
Kruse  KE, Batten  J, Constantine  ML, Kache  S, Magnus  D.  Challenges to code status discussions for pediatric patients.  PLoS One. 2017;12(11):e0187375. doi:10.1371/journal.pone.0187375PubMedGoogle ScholarCrossref
49.
Findlay  GP, Shotton  H, Kelly  K, Mason  M. Time to intervene? a review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest: a report by the National Confidential Enquiry Into Patient Outcome and Death (2012). https://www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf. Published 2012. Accessed July 8, 2018.
50.
Field  RA, Fritz  Z, Baker  A, Grove  A, Perkins  GD.  Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions.  Resuscitation. 2014;85(11):1418-1431. doi:10.1016/j.resuscitation.2014.08.024PubMedGoogle ScholarCrossref
51.
Mockford  C, Fritz  Z, George  R,  et al.  Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation.  Resuscitation. 2015;88:99-113. doi:10.1016/j.resuscitation.2014.11.016PubMedGoogle ScholarCrossref
52.
SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) [published correction appears in JAMA. 1996;275(16):1232].  JAMA. 1995;274(20):1591-1598. PubMedGoogle ScholarCrossref
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    Views 2,249
    Original Investigation
    Emergency Medicine
    June 7, 2019

    Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
    • 2Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
    • 3Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
    • 4Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
    • 5University Medical Library, University of Basel, Basel, Switzerland
    • 6Quality Management, University Hospital Basel, Basel, Switzerland
    • 7Medical Faculty, University of Basel, Basel, Switzerland
    JAMA Netw Open. 2019;2(6):e195033. doi:10.1001/jamanetworkopen.2019.5033
    Key Points español 中文 (chinese)

    Question  Is there an association between communication interventions and patient preference regarding do-not-resuscitate (DNR) code status decisions and knowledge regarding life-sustaining treatment?

    Findings  In this systematic review and meta-analysis, the pooled meta-analysis of 11 randomized clinical trials involving 1463 patients showed a significant association between communication interventions and higher patient preference for a DNR code status. In an analysis of 5 eligible trials, communication interventions were also associated with better patient knowledge about resuscitation.

    Meaning  Communication interventions may be an effective decision aid for code status discussions that potentially alter patient decisions regarding DNR code status and increase patient knowledge.

    Abstract

    Importance  Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear.

    Objective  To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR.

    Data Sources  PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018.

    Study Selection  Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported.

    Data Extraction and Synthesis  The study was performed according to the PRISMA guidelines.

    Main Outcomes and Measures  The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment.

    Results  Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71).

    Conclusions and Relevance  Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.

    Introduction

    To inform patients about treatment options in case of a cardiac arrest and their involvement in the decision-making process regarding their code status is considered a cornerstone of patient-centered care.1 Physicians are encouraged to conduct such code status discussions to respect patient autonomy as an ethical principle.2-4 Also, it is important to ask hospitalized patients for their preference because cardiopulmonary arrest occurs in almost 1 per 1000 hospitalization days.5

    However, the literature reports several shortcomings and challenges in conducting code status discussions. First, many patients have unrealistic expectations about cardiopulmonary resuscitation (CPR) and associated risks and benefits.6,7 Patients with in-hospital cardiac arrests generally have a poor prognosis, with a survival to hospital discharge rate less than 20%.8,9 Beyond, many survivors have substantial neurologic deficits, limiting the potential to live an independent life.10

    However, physicians often omit code status discussions or do not describe resuscitation measures, such as chest compressions or mechanical ventilation.11 Although CPR is an invasive procedure with potential complications, risks and benefits are usually not communicated adequately to patients, contributing further to patient misconceptions.12,13

    A recent study14 in patients with cancer found that physicians document a presumed code status rather than conduct a true discussion, leading to a high proportion of full code status. Almost one-third of patients who were documented as full code would have preferred a do-not-resuscitate (DNR) code status if adequately informed about the consequences of CPR.14

    Moreover, code status discussions are often ineffective due to poor communication skills of physicians.15,16 This is particularly true for junior physicians, who conduct most of the code status discussions in clinical practice and often perceive themselves as unprepared to explain complex medical procedures.17 Furthermore, code status discussions are often conducted under time constraints in an impersonalized, procedure-focused way, missing the chance to focus on individual patient values and goals.18-21 A recent study22 from Switzerland found that treating physicians significantly altered patient choices, raising the question of patient autonomy.

    To date, there is no consensus about the best approach to code status discussions to understand patient preference and choice regarding DNR code status. The objective of this systematic review and meta-analysis was to identify studies examining communication interventions designed to facilitate code status discussions. We were especially interested in the association of communication interventions with patient preference for CPR or DNR code status and knowledge regarding resuscitation and its outcome.

    Methods
    Types of Studies, Participants, and Outcome Measures

    This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines.23 We included randomized clinical trials (RCTs) in which the association of communication interventions during code status discussions with patient-relevant outcomes was compared with a control group. Studies were eligible if they focused on the outcomes of patient preference for resuscitation or DNR or patient knowledge regarding life-sustaining treatment.

    Search Terms for Identification of Studies

    We performed a comprehensive search strategy consisting of a combination of Medical Subject Headings and free-text words. We searched PubMed, Embase, PsycINFO, and CINAHL.

    We developed the search strategy in consultation with a medical librarian (H.E.) experienced in systematic reviews. Initial search terms were drawn from a small set of key articles. We used an iterative process of building a search strategy, running the search, scanning the relevant retrieved articles for additional terms, and then rebuilding the search strategy with the newly identified relevant terms and related Medical Subject Headings. Because we focused on RCTs, we also used a sensitivity and precision-maximizing RCT filter for our search.24 The final search strategy for PubMed, which was adapted for the other databases, is available in the Appendix (eTable 1 in the Supplement).

    To identify additional published, unpublished, and ongoing studies, we (1) tracked relevant references through the cited reference search of Web of Science and PubMed, (2) applied the similar articles search of PubMed, and (3) screened all references of potentially eligible studies. The data search was performed between September 3 and November 19, 2018.

    Study Selection

    Two of us (C.B. and L.L.) screened the titles and abstracts of articles found by the systematic search strategy. Studies were selected according to the inclusion criteria. We read the full texts of studies considered eligible for inclusion, and disagreement was resolved by discussion and consensus. Studies with the same assessment of end points were selected for quantitative meta-analysis regarding the association of communication interventions with primary and secondary end points.

    Data Extraction and Assessment of Methodological Quality

    Two of us (C.B. and L.L.) independently extracted the data of the included studies. Relevant outcomes for our systematic review and meta-analysis were patient preference for resuscitation or DNR code status and knowledge regarding CPR.

    The RCTs were assessed for methodological quality using the Cochrane Risk of Bias Tool to rate the risk of bias in random sequence generation, allocation concealment, selective reporting, masking, completeness of outcome data, and other possible bias25 (eTable 2 in the Supplement). If at least 1 of the domains was rated as high risk, the trial was considered at high risk of bias. If all domains were judged as low, the trial was considered to be at low risk of bias. Otherwise, the trial was considered at unclear risk of bias. Two of us (C.B. and L.L.) performed data extraction and risk of bias assessment independently; disagreement was resolved by involvement of a third author (S. Hunziker).

    Data Analysis

    We express dichotomous data risk ratios (RRs) with 95% CIs and report continuous data as the mean differences with 95% CIs. Data were pooled using a fixed-effects model. We identified heterogeneity (inconsistency) through visual inspection of the forest plots. We used the I2 statistic, which quantifies inconsistency across studies, to assess the consequences of heterogeneity on the meta-analysis. An I2 statistic of 50% or more indicates a considerable level of heterogeneity. If data were not suitable for direct comparison, we applied narrative synthesis.

    For the primary end point, we performed several predefined subgroup analyses that stratified the results based on the following: type of intervention (video intervention vs no video intervention), age (<75 vs ≥75 years), risk of bias according to the Cochrane Risk of Bias Tool, study setting (outpatients vs hospitalized patients), marital status (≤65% vs >65% of patients married), education of the population (>30% vs ≤30% with a college degree or higher), and sex (≤55% vs >55% male). These cutoffs for stratification were chosen post hoc based on the distribution among trials to achieve a balanced number of patients per group. For the secondary end point, we performed several predefined subgroup analyses stratifying the results based on age (<75 vs ≥75 years) and risk of bias.

    Statistical analyses were performed using the METAN package in Stata (Stata MP, version 15.1; StataCorp LP). Two-sided P < .05 was considered statistically significant.

    Results
    Studies Identified

    A total of 7001 records were identified through our database searches. We removed duplicates (n = 1203) and discarded 5206 studies after examining titles and 559 studies after screening abstracts. Of the remaining 33 full-text articles, 15 studies26-40 were eligible for inclusion (eFigure in the Supplement). Six studies were judged to be at low risk of bias, 4 studies at high risk of bias, and 5 studies at unclear risk of bias.

    Description of Studies

    Table 1 lists characteristics of the 15 included RCTs. Publication dates ranged from 1999 to 2018, and studies were conducted mostly in the United States (14 trials26-35,37-40), with 1 trial36 from Australia. Across all studies, a total of 2405 participants were included, with study sample sizes ranging from 50 to 313 per trial. In 8 studies,26,27,31-33,35,36,39 participants were recruited among hospitalized patients, and a further 5 studies28,29,34,38,40 recruited outpatients, whereas 1 study37 investigated residents of a nursing facility and 1 study30 recruited outpatients and hospitalized patients.

    Eight studies26-30,34,36,38 used advanced diseases with a life expectancy less than 1 year, such as metastatic cancer, end-stage congestive heart, or renal failure, as the inclusion criteria, while 7 studies31-33,35,37,39,40 had no exclusion criteria based on illness. The mean age of the study population was 60 years or older in 12 studies. Six studies26,27,31,35,37,40 only recruited patients older than 60 or 65 years. Eleven studies assessed the outcome of preference for DNR of intervention vs control groups, and 8 studies assessed knowledge regarding CPR.

    All studies used a dichotomous format (yes or no) to investigate the association of communication interventions with patient preference for CPR. Patient knowledge was assessed through questionnaires; 5 studies used the same questionnaire as in a previous study.41

    Eleven included studies26-29,31,34,35,37-40 applied a video-based intervention. Ten videos showed simulated cardiac arrests and medical procedures undertaken during CPR, such as chest compressions and intubation. Some videos also contained images of real patients being treated on intensive care units, and other videos also provided information regarding end-of-life care or advance directives.37,40 Other studies used designed advance care planning interviews,30 standardized scripted explanations,32,33 or written information36 as interventions.

    All studies used either structured questionnaires or interviews for data collection. One study30 did not specify assessment of preference for CPR.

    Quantitative Analysis
    Primary End Point of Preference for CPR

    Of the 15 eligible trials, 4 did not report data regarding patient preference for resuscitation and were excluded from the quantitative analysis. The remaining 11 trials26-31,35-38,40 (1463 patients) were pooled for the meta-analysis (Figure 1).

    Five of these 11 studies reported no significant association of interventions with patient preference for CPR, and 6 trials reported a significant decrease in preference for CPR. Compared with usual care, the pooled results showed a significant association between the communication interventions and a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). There was high heterogeneity among trials (I2 = 81.2%; P < .001).

    Stratification by Type of Intervention, Age, Risk of Bias, Study Setting, Marital Status, Education, and Sex

    To assess the association of communication interventions with patient preference for CPR in predefined subgroups, we stratified our results by type of intervention, age, risk of bias, study setting, marital status of participants, education, and sex (Table 2). When stratified by type of intervention, trials that used videos showing resuscitation as a decision aid in their intervention group compared with other types of interventions demonstrated a stronger decrease in preference for CPR (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Studies with low risk of bias had a stronger association with lower preference for CPR compared with trials with higher risk of bias (RR, 0.52; 95% CI, 0.43-0.63 vs 0.87; 95% CI, 0.76-0.99; between-group heterogeneity P < .001). Stratification by study setting also showed no difference between outpatients and hospitalized patients (RR, 0.64; 95% CI, 0.51-0.79 vs 0.71; 95% CI, 0.60-0.85; between-group heterogeneity P = .82). When stratified by marital status, the intervention had a stronger association with lower preference for CPR in trials with no more than 65% vs greater than 65% of patients being married (RR, 0.47; 95% CI, 0.38-0.58 vs 0.84; 95% CI, 0.50-1.39; between-group heterogeneity P = .02).

    Also, interventions had a stronger association with decreased preference for CPR in trials of patients with low education level (ie, ≤30% with college degree or higher) (RR, 0.48; 95% CI, 0.39-0.59 vs 0.94; 95% CI, 0.74-1.18; between-group heterogeneity P < .001). Regarding demographics, interventions had stronger association with reduced preference for CPR in trials that included older patients (≥75 years) compared with younger patients (RR, 0.58; 95% CI, 0.50-0.68 vs 0.86; 95% CI, 0.73-1.01; between-group heterogeneity P = .003) and in trials that had larger proportions of male patients (>55% vs ≤55% male) (RR, 0.49; 95% CI, 0.40-0.59 vs 0.68; 95% CI, 0.54-0.85; between-group heterogeneity P < .001).

    Secondary End Points
    Key Secondary End Point of Knowledge

    Patient knowledge regarding CPR was assessed in 10 studies. Five trials used varying instruments to measure knowledge, which could not be standardized. We pooled the remaining 5 trials26-29,37 (including 652 patients) that used the exact same questionnaire for meta-analysis. In the pooled analysis, we found a significant association between communication interventions and higher patient knowledge (overall standardized mean difference [SMD], 0.55; 95% CI, 0.39-0.71). There was some heterogeneity among trials (I2 = 53.9%; P = .07) (Figure 2).

    We then stratified the analysis by age and risk of bias. In low-risk trials, there was a stronger association between communication interventions and higher knowledge compared with higher-risk trials (SMD, 0.60; 95% CI, 0.43-0.77 vs 0.28; 95% CI, −0.10 to 0.67; between-group heterogeneity P = .14). Stratification by age did not show a significant difference between older and younger patients (SMD, 0.59; 95% CI, 0.39-0.80 vs 0.48; 95% CI, 0.23-0.73; between-group heterogeneity P = .48).

    Other Patient-Relevant Outcomes

    Three studies29,33,40 evaluated the associations of communication interventions with completion or presence of advance directives; however, they had too much heterogeneity to be included in a meta-analysis. Nicolasora et al33 assessed new completion rates of advance directives at hospital discharge and found that the intervention led to a significantly higher proportion of completed advance directives (0.8% vs 12.7%; P < .001). Yamada et al40 investigated the same topic 4 weeks after hospital discharge but also included patients who intended to fill out an advance directive, without reporting specific numbers. According to the authors, their results showed no significant findings. Epstein et al29 looked at advance care planning documentation overall, which included advance directives. It was not reported whether advance directives were completed in relation to the video intervention or whether they had already been in place before the study. The study found no statistical difference between the video intervention and control groups.

    Several studies that used videos as decision aids assessed patient perception regarding the video intervention by ratings on a Likert-type scale.26-29,37,39 According to the results of those studies, patients generally were more comfortable watching a video, rating its content as useful or helpful in the process of decision making. One study28 used the Decisional Conflict Scale as a validated questionnaire to assess patient decision-making ability. In that study, the mean uncertainty score was significantly higher in the video group compared with the control group (13.7; 95% CI, 12.8-14.6 vs 11.5; 95% CI, 10.5-12.6; P = .002), indicating less uncertainty among patients who had seen the video in choosing between their treatment options.

    Physician-Relevant Outcomes

    One study31 investigating the effect of a video as a decision aid among 119 patients hospitalized on a general medical ward asked them about trust in their treating health care team as a secondary outcome. Trust was assessed on a 5-point Likert-type scale ranging from “agree” to “disagree.” There was no significant difference between groups (76% vs 93%; P = .08).

    Rhondali et al34 investigated the extent to which patients perceived their physician as compassionate. Patients saw videos showing simulated code status discussions. Videos ended either with the physician making a recommendation or asking about patient preference. Independent of their allocated group, patients who opted for full code rated their physician as less compassionate than patients who opted for comfort care.

    Discussion

    The findings of this systematic review and meta-analysis investigating associations between communication interventions to discuss code status and patient preference for resuscitation and patient knowledge regarding life-sustaining measures and outcome are 3-fold. First, we found a strong association between communication interventions and patient decisions regarding DNR code status, with lower preference for life-sustaining therapies if patients received a communication intervention compared with usual care. This association was more pronounced in studies with lower risk of bias. Second, associations between communication interventions and patient preference for a DNR code status were stronger when video-assisted decision aids were used, in trials that included older patients, in men, and among patients with lower healthy literacy. However, it is important to note that only a limited number of video interventions were tested in different settings. Third, communication interventions were also associated with better knowledge regarding resuscitation measures and the outcome of cardiac arrests. Again, trials with lower risk of bias had a stronger association with patient knowledge.

    In line with our results demonstrating that more information delivered by communication interventions is associated with a higher probability for patients to choose a DNR code status, a previous trial38 found that health literacy (the ability to comprehend medical consequences) is a predictor of patient choice of DNR status. Therefore, more information may help patients make individualized informed decisions regarding resuscitation measures. Today, shared end-of-life decision making is considered an ethical obligation of patient-centered care to discuss equivalent treatment options, emphasizing patient autonomy and self-determination.1,42-44 However, decision making during code status discussions is often challenged by uncertainty surrounding interventions and therapies that might be available but whose outcomes remain uncertain.45,46 The results of the present systematic review and meta-analysis suggest that communication interventions, including video-assisted ones, enable patients to actively participate in the decision-making process by increasing their knowledge. This assumption is supported by a study28 using video that found a simultaneous increase in patient knowledge and decrease in decisional conflict regarding choice of care.

    Previous studies11,47,48 reported variable quality of health care providers’ communication skills with hospitalized patients regarding code status. Herein, videos had the potential to inform patients in a standardized way and thereby promote shared decision making. However, interventions using visual components (eg, chest compressions, intubation, and ventilation) have been criticized because they may influence patients and lead them to a particular treatment choice. Furthermore, video tools as decision aids might not be applicable in some clinical settings due to limited accessibility and may be not suitable for elderly patients. Yet, some studies26-29,37,38 using Likert-type scales to assess patient comfort reported that patients were comfortable with watching a resuscitation video. However, there is also concern that videos as a decision aid might impair the patient-physician relationship. In 1 study,31 patients receiving a video intervention reported less trust in their treating health care team. In a study4 of advance care planning interventions, patients who opted for life-sustaining treatment perceived their physician as less compassionate, suggesting that these patients might not have approved of the video approach. Hence, video-assisted interventions may be useful adjuvants for code status discussions but should not be a substitute for direct patient-physician communication. A more flexible approach that can be adapted to individual patient needs might be more favorable and easier to implement in busy clinical environments.

    A 2012 British multicenter cohort study49 investigated medical records of patients who had undergone resuscitation after an in-hospital cardiac arrest. In more than 75% of patients who received CPR, the code status was unknown, and 67% of patients who were resuscitated had an underlying preexisting fatal disease. An independent post hoc assessment of all cases found that a DNR status would have been appropriate in 85% because the risk-benefit ratio was unfavorable for these patients. As in patients with diseases for which they are receiving palliative care, CPR is not beneficial and may even prolong the dying process.3 In addition, we found that the interventions of our studies herein were associated with a greater reduction in patient preference for CPR in patients 75 years or older compared with younger patients. Also, in patients with a poor prognosis, we observed that the interventions had a stronger association with patient choice of a DNR code status. Therefore, such patients may receive the most benefit from communication interventions.

    In general, a patient decision regarding DNR code status is a legal order to withhold CPR or advanced cardiac life support in case of cardiac arrest or respiratory failure and has important medical and socioeconomic consequences.50,51 Those 2 systematic reviews found variability in DNR decision making and implementation of DNR code status, leading to suboptimal care with undesired withdrawal of treatment in case of clinical deterioration. A standardized decision-making and documentation process of code status discussions may thus help improve quality of care and enable physicians to make decisions in the best interest of their patients. Today, an increasing number of hospitals and care centers use medical decision systems, such as Physician Orders for Scope of Treatment (POLST), Medical Orders for Scope of Treatment (MOLST), or Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embed treatment plans in case of clinical deterioration. Based on our findings, it would be relevant to integrate communication interventions into such decision systems to further improve the uniformity of clinical care and strengthen patient involvement in the decision process.

    In 1995, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT),52 a landmark trial to investigate different approaches to improve care for seriously ill patients, reported shortcomings in communication during code status discussions. Despite all research efforts over more than 20 years, there is still need for large and high-quality RCTs focusing on interventions to facilitate code status discussions. In our systematic review and meta-analysis, we found only 3 studies30,32,33 that investigated interventions other than videos on patient preference for care and knowledge regarding resuscitation. There is clearly need for further trials regarding this important topic.

    Limitations

    We are aware of several limitations to this systematic review and meta-analysis. The meta-analysis is based on a small number of trials and patients that could be considered for the quantitative analysis, and additional research is needed to confirm these results. A large proportion of trials targeted a population of terminally ill patients with a life expectancy less than 1 year, and generalizability to other patient populations is thus limited. In addition, the study populations were similar regarding ethnicity (mostly white) and age group (most were aged ≥60 years), again limiting generalizability of our results. Furthermore, most trials were performed in the United States, limiting transferability to other populations due to differences in medical and socioeconomic systems. Also, 5 of our 15 RCTs were performed by the same 2 groups of investigators (ie, by El-Jawahri et al26-28 and by Volandes et al37,38), and the findings from their trials had stronger effects compared with trials from other groups regarding patient preference for a DNR code status. However, those 5 studies had low risk of bias, and trials were performed in different settings (ie, outpatients vs hospitalized patients) and with different patient populations (ie, those with palliative vs curative diseases). Therefore, validation of our results by independent research groups is warranted. The number of trials and patients was small, also limiting interpretation of our subgroup analyses and increasing the risk for type II error.

    Conclusions

    Communication interventions may be an effective decision aid for code status discussions, potentially altering patient preference and increasing patient knowledge. More informed patients may be better able to participate in the decision-making process, which might prevent unwanted excessive medical procedures. There is still urgent need for large-scale RCTs to investigate further approaches to facilitate code status discussions.

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    Article Information

    Accepted for Publication: April 16, 2019.

    Published: June 7, 2019. doi:10.1001/jamanetworkopen.2019.5033

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Becker C et al. JAMA Network Open.

    Corresponding Author: Sabina Hunziker, MD, MPH, Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland (sabina.hunziker@usb.ch).

    Author Contributions: Drs Becker and Hunziker had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Becker, Lecheler, Rueter, Schaefert, Bassetti, Hunziker.

    Acquisition, analysis, or interpretation of data: Becker, Lecheler, Hochstrasser, Metzger, Widmer, Thommen, Nienhaus, Ewald, Meier, Schaefert, Hunziker.

    Drafting of the manuscript: Becker, Lecheler.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Becker, Lecheler, Hunziker.

    Administrative, technical, or material support: Metzger, Nienhaus, Ewald, Meier, Rueter, Schaefert, Hunziker.

    Supervision: Rueter, Schaefert, Hunziker.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Committee on Quality of Health Care in America, Institute of Medicine.  Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
    2.
    Keyserlingk  EW.  Review of report: Deciding to Forego Life-Sustaining Treatment (President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Washington, DC, March, 1983).  Health Law Can. 1984;4(4):103-107.PubMedGoogle Scholar
    3.
    Council on Ethical and Judicial Affairs, American Medical Association.  Guidelines for the appropriate use of do-not-resuscitate orders.  JAMA. 1991;265(14):1868-1871. doi:10.1001/jama.1991.03460140096034PubMedGoogle ScholarCrossref
    4.
    Kass-Bartelmes  BL, Hughes  R.  Advance care planning: preferences for care at the end of life.  J Pain Palliat Care Pharmacother. 2004;18(1):87-109.PubMedGoogle Scholar
    5.
    Overdyk  FJ, Dowling  O, Marino  J,  et al.  Association of opioids and sedatives with increased risk of in-hospital cardiopulmonary arrest from an administrative database.  PLoS One. 2016;11(2):e0150214. doi:10.1371/journal.pone.0150214PubMedGoogle ScholarCrossref
    6.
    Marco  CA, Larkin  GL.  Cardiopulmonary resuscitation: knowledge and opinions among the U.S. general public: state of the science-fiction [published correction appears in Resuscitation. 2009;80(3):389].  Resuscitation. 2008;79(3):490-498. doi:10.1016/j.resuscitation.2008.07.013PubMedGoogle ScholarCrossref
    7.
    Diem  SJ, Lantos  JD, Tulsky  JA.  Cardiopulmonary resuscitation on television: miracles and misinformation.  N Engl J Med. 1996;334(24):1578-1582. doi:10.1056/NEJM199606133342406PubMedGoogle ScholarCrossref
    8.
    Perkins  GD, Cooke  MW.  Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators.  Emerg Med J. 2012;29(1):3-5. doi:10.1136/emermed-2011-200758PubMedGoogle ScholarCrossref
    9.
    Meaney  PA, Nadkarni  VM, Kern  KB, Indik  JH, Halperin  HR, Berg  RA.  Rhythms and outcomes of adult in-hospital cardiac arrest.  Crit Care Med. 2010;38(1):101-108. doi:10.1097/CCM.0b013e3181b43282PubMedGoogle ScholarCrossref
    10.
    Perkins  GD, Temple  RM, George  R.  Time to intervene: lessons from the NCEPOD report.  Resuscitation. 2012;83(11):1305-1306. doi:10.1016/j.resuscitation.2012.08.332PubMedGoogle ScholarCrossref
    11.
    Tulsky  JA, Chesney  MA, Lo  B.  How do medical residents discuss resuscitation with patients?  J Gen Intern Med. 1995;10(8):436-442. doi:10.1007/BF02599915PubMedGoogle ScholarCrossref
    12.
    Einstein  DJ, Einstein  KL, Mathew  P.  Dying for advice: code status discussions between resident physicians and patients with advanced cancer: a national survey.  J Palliat Med. 2015;18(6):535-541. doi:10.1089/jpm.2014.0373PubMedGoogle ScholarCrossref
    13.
    Anderson  WG, Chase  R, Pantilat  SZ, Tulsky  JA, Auerbach  AD.  Code status discussions between attending hospitalist physicians and medical patients at hospital admission.  J Gen Intern Med. 2011;26(4):359-366. doi:10.1007/s11606-010-1568-6PubMedGoogle ScholarCrossref
    14.
    El-Jawahri  A, Lau-Min  K, Nipp  RD,  et al.  Processes of code status transitions in hospitalized patients with advanced cancer.  Cancer. 2017;123(24):4895-4902. doi:10.1002/cncr.30969PubMedGoogle ScholarCrossref
    15.
    Tulsky  JA, Fischer  GS, Rose  MR, Arnold  RM.  Opening the black box: how do physicians communicate about advance directives?  Ann Intern Med. 1998;129(6):441-449. doi:10.7326/0003-4819-129-6-199809150-00003PubMedGoogle ScholarCrossref
    16.
    Covinsky  KE, Fuller  JD, Yaffe  K,  et al.  Communication and decision-making in seriously ill patients: findings of the SUPPORT project: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.  J Am Geriatr Soc. 2000;48(S1)(suppl):S187-S193. doi:10.1111/j.1532-5415.2000.tb03131.xPubMedGoogle ScholarCrossref
    17.
    Billings  ME, Curtis  JR, Engelberg  RA.  Medicine residents’ self-perceived competence in end-of-life care.  Acad Med. 2009;84(11):1533-1539. doi:10.1097/ACM.0b013e3181bbb490PubMedGoogle ScholarCrossref
    18.
    Deep  KS, Griffith  CH, Wilson  JF.  Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.  J Gen Intern Med. 2008;23(11):1877-1882. doi:10.1007/s11606-008-0779-6PubMedGoogle ScholarCrossref
    19.
    Momen  NC, Barclay  SI.  Addressing “the elephant on the table”: barriers to end of life care conversations in heart failure: a literature review and narrative synthesis.  Curr Opin Support Palliat Care. 2011;5(4):312-316. doi:10.1097/SPC.0b013e32834b8c4dPubMedGoogle ScholarCrossref
    20.
    Knauft  E, Nielsen  EL, Engelberg  RA, Patrick  DL, Curtis  JR.  Barriers and facilitators to end-of-life care communication for patients with COPD.  Chest. 2005;127(6):2188-2196. doi:10.1378/chest.127.6.2188PubMedGoogle ScholarCrossref
    21.
    Visser  M, Deliens  L, Houttekier  D.  Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review.  Crit Care. 2014;18(6):604. doi:10.1186/s13054-014-0604-zPubMedGoogle ScholarCrossref
    22.
    Siegrist  V, Eken  C, Nickel  CH, Mata  R, Hertwig  R, Bingisser  R.  End-of-life decisions in emergency patients: prevalence, outcome, and physician effect [published online May 30, 2018].  QJM. doi:10.1093/qjmed/hcy112PubMedGoogle Scholar
    23.
    Moher  D, Liberati  A, Tetzlaff  J, Altman  DG; PRISMA Group.  Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement [published correction appears in Int J Surg. 2010;8(8):658].  Int J Surg. 2010;8(5):336-341. doi:10.1016/j.ijsu.2010.02.007PubMedGoogle ScholarCrossref
    24.
    Lefebvre  C, Manheimer  E, Glanville  J. Chapter 6: searching for studies. In: Higgins J, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. West Sussex, England: John Wiley & Sons; 2011:95-150. http://handbook-5-1.cochrane.org/. Updated March 2011. Accessed April 26, 2019.
    25.
    Higgins  JP, Altman  DG, Gøtzsche  PC,  et al; Cochrane Bias Methods Group; Cochrane Statistical Methods Group.  The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.  BMJ. 2011;343:d5928. doi:10.1136/bmj.d5928PubMedGoogle ScholarCrossref
    26.
    El-Jawahri  A, Mitchell  SL, Paasche-Orlow  MK,  et al.  A randomized controlled trial of a CPR and intubation video decision support tool for hospitalized patients.  J Gen Intern Med. 2015;30(8):1071-1080. doi:10.1007/s11606-015-3200-2PubMedGoogle ScholarCrossref
    27.
    El-Jawahri  A, Paasche-Orlow  MK, Matlock  D,  et al.  Randomized, controlled trial of an advance care planning video decision support tool for patients with advanced heart failure.  Circulation. 2016;134(1):52-60. doi:10.1161/CIRCULATIONAHA.116.021937PubMedGoogle ScholarCrossref
    28.
    El-Jawahri  A, Podgurski  LM, Eichler  AF,  et al.  Use of video to facilitate end-of-life discussions with patients with cancer: a randomized controlled trial [published correction appears in J Clin Oncol. 2010;28(8):1438].  J Clin Oncol. 2010;28(2):305-310. doi:10.1200/JCO.2009.24.7502PubMedGoogle ScholarCrossref
    29.
    Epstein  AS, Volandes  AE, Chen  LY,  et al.  A randomized controlled trial of a cardiopulmonary resuscitation video in advance care planning for progressive pancreas and hepatobiliary cancer patients.  J Palliat Med. 2013;16(6):623-631. doi:10.1089/jpm.2012.0524PubMedGoogle ScholarCrossref
    30.
    Kirchhoff  KT, Hammes  BJ, Kehl  KA, Briggs  LA, Brown  RL.  Effect of a disease-specific advance care planning intervention on end-of-life care.  J Am Geriatr Soc. 2012;60(5):946-950. doi:10.1111/j.1532-5415.2012.03917.xPubMedGoogle ScholarCrossref
    31.
    Merino  AM, Greiner  R, Hartwig  K.  A randomized controlled trial of a CPR decision support video for patients admitted to the general medicine service.  J Hosp Med. 2017;12(9):700-704. doi:10.12788/jhm.2791PubMedGoogle ScholarCrossref
    32.
    Mittal  K, Sharma  K, Dangayach  N,  et al.  Use of a standardized code status explanation by residents among hospitalized patients.  J Community Hosp Intern Med Perspect. 2014;4:4.PubMedGoogle Scholar
    33.
    Nicolasora  N, Pannala  R, Mountantonakis  S,  et al.  If asked, hospitalized patients will choose whether to receive life-sustaining therapies.  J Hosp Med. 2006;1(3):161-167. doi:10.1002/jhm.78PubMedGoogle ScholarCrossref
    34.
    Rhondali  W, Perez-Cruz  P, Hui  D,  et al.  Patient-physician communication about code status preferences: a randomized controlled trial.  Cancer. 2013;119(11):2067-2073. doi:10.1002/cncr.27981PubMedGoogle ScholarCrossref
    35.
    Richardson-Royer  C, Naqvi  I, Riffel  C,  et al.  A video depicting resuscitation did not impact upon patients’ decision-making.  Int J Gen Med. 2018;11:73-77. doi:10.2147/IJGM.S147109PubMedGoogle ScholarCrossref
    36.
    Stein  RA, Sharpe  L, Bell  ML, Boyle  FM, Dunn  SM, Clarke  SJ.  Randomized controlled trial of a structured intervention to facilitate end-of-life decision making in patients with advanced cancer.  J Clin Oncol. 2013;31(27):3403-3410. doi:10.1200/JCO.2011.40.8872PubMedGoogle ScholarCrossref
    37.
    Volandes  AE, Brandeis  GH, Davis  AD,  et al.  A randomized controlled trial of a goals-of-care video for elderly patients admitted to skilled nursing facilities.  J Palliat Med. 2012;15(7):805-811. doi:10.1089/jpm.2011.0505PubMedGoogle ScholarCrossref
    38.
    Volandes  AE, Paasche-Orlow  MK, Mitchell  SL,  et al.  Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer.  J Clin Oncol. 2013;31(3):380-386. doi:10.1200/JCO.2012.43.9570PubMedGoogle ScholarCrossref
    39.
    Wilson  ME, Krupa  A, Hinds  RF,  et al.  A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial.  Crit Care Med. 2015;43(3):621-629. doi:10.1097/CCM.0000000000000749PubMedGoogle ScholarCrossref
    40.
    Yamada  R, Galecki  AT, Goold  SD, Hogikyan  RV.  A multimedia intervention on cardiopulmonary resuscitation and advance directives.  J Gen Intern Med. 1999;14(9):559-563. doi:10.1046/j.1525-1497.1999.11208.xPubMedGoogle ScholarCrossref
    41.
    Kerridge  IH, Pearson  SA, Rolfe  IE, Lowe  M, McPhee  JR.  Impact of written information on knowledge and preferences for cardiopulmonary resuscitation.  Med J Aust. 1999;171(5):239-242. doi:10.5694/j.1326-5377.1999.tb123629.xPubMedGoogle ScholarCrossref
    42.
    Council on Scientific Affairs, American Medical Association.  Good care of the dying patient.  JAMA. 1996;275(6):474-478. doi:10.1001/jama.1996.03530300058041PubMedGoogle ScholarCrossref
    43.
    Lo  B, Snyder  L.  Care at the end of life: guiding practice where there are no easy answers.  Ann Intern Med. 1999;130(9):772-774. doi:10.7326/0003-4819-130-9-199905040-00018PubMedGoogle ScholarCrossref
    44.
    Lynn  J.  Measuring quality of care at the end of life: a statement of principles.  J Am Geriatr Soc. 1997;45(4):526-527. doi:10.1111/j.1532-5415.1997.tb05184.xPubMedGoogle ScholarCrossref
    45.
    Rocker  G, Cook  D, Sjokvist  P,  et al; Level of Care Study Investigators; Canadian Critical Care Trials Group.  Clinician predictions of intensive care unit mortality.  Crit Care Med. 2004;32(5):1149-1154. doi:10.1097/01.CCM.0000126402.51524.52PubMedGoogle ScholarCrossref
    46.
    Curtis  JR, Vincent  JL.  Ethics and end-of-life care for adults in the intensive care unit.  Lancet. 2010;376(9749):1347-1353. doi:10.1016/S0140-6736(10)60143-2PubMedGoogle ScholarCrossref
    47.
    Azoulay  E, Chevret  S, Leleu  G,  et al.  Half the families of intensive care unit patients experience inadequate communication with physicians.  Crit Care Med. 2000;28(8):3044-3049. doi:10.1097/00003246-200008000-00061PubMedGoogle ScholarCrossref
    48.
    Kruse  KE, Batten  J, Constantine  ML, Kache  S, Magnus  D.  Challenges to code status discussions for pediatric patients.  PLoS One. 2017;12(11):e0187375. doi:10.1371/journal.pone.0187375PubMedGoogle ScholarCrossref
    49.
    Findlay  GP, Shotton  H, Kelly  K, Mason  M. Time to intervene? a review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest: a report by the National Confidential Enquiry Into Patient Outcome and Death (2012). https://www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf. Published 2012. Accessed July 8, 2018.
    50.
    Field  RA, Fritz  Z, Baker  A, Grove  A, Perkins  GD.  Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions.  Resuscitation. 2014;85(11):1418-1431. doi:10.1016/j.resuscitation.2014.08.024PubMedGoogle ScholarCrossref
    51.
    Mockford  C, Fritz  Z, George  R,  et al.  Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation.  Resuscitation. 2015;88:99-113. doi:10.1016/j.resuscitation.2014.11.016PubMedGoogle ScholarCrossref
    52.
    SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) [published correction appears in JAMA. 1996;275(16):1232].  JAMA. 1995;274(20):1591-1598. PubMedGoogle ScholarCrossref
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