Cardiac arrest: resuscitation orders: neither physicians nor family members were good at guessing elderly patients' wishes

Clinical bottom line (level 1b)

  1. Most elderly patients wished to be resuscitated following a cardiac arrest.
  2. Physicians were unable to predict whether healthy elderly patients wish to be resuscitated following a cardiac arrest.
  3. Family members were unable to predict whether healthy elderly patients wish to be resuscitated following a cardiac arrest, but could help identify patients who did not want CPR.
Seckler et al: Annals of Internal Medicine 1991; 115: 92-98
Expires October 2003

The study

Setting: geriatric outpatient clinic, university hospital, USA

70 patients (aged 65 to 93; mean 78, 80% female)

Excluded if
  • incomplete comprehension of the concept of resuscitation
  • unable to speak English
  • dementia (Mini-Mental State Exam > 20)



    • Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • patients were informed about resuscitation, then asked if they wished to be resuscitated in their current state of health or if they were demented
    Diagnostic test:
    • physician's prediction of patient's resuscitation wishes
    • family member's prediction of patient's resuscitation wishes

    The evidence

    pre-test probability of patient's desire to be resuscitated: 88%, (95% CI: 81% to 96%)

    diagnostic test CPR wanted or uncertain no CPR wanted LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    physician believed patient wanted CPR 47 5 1.2
    (0.71 to 2.2)     		90% 0.61
    (0.22 to 1.7)     		82%
    family member believed patient wanted CPR 48 4 1.4
    (0.8 to 2.5)     		92% 0.18
    (0.036 to 0.85)     		60%
    total 61 8

    Comments

    1. 57 family members could be contacted - of these 51 patients said they wanted to be resuscitated.
    2. Most patients felt that their family members and physicians would accurately or fairly accurately predict their resuscitation wishes.
    3. Physicians and family members were no better at predicting what patients would wish if they became demented.

    Citation

    1. Seckler AB, Meier DE, Mulvihill M, et al: Substituted judgement: how accurate are proxy predictions?. Annals of Internal Medicine 1991; 115: 92-98
    Contributor: Chris Ball and Clare Wotton, October 1999
    Reviewer:

    Clinical Question.
    Patient healthy elderly
    Intervention or Exposure family member or physician's predication of resuscitation wishes
    Outcome patient's resuscitation wishes