PREFERENCES FOR CARDIOPULMONARY-RESUSCITATION - PHYSICIAN-PATIENT AGREEMENT AND HOSPITAL RESOURCE USE

OBJECTIVE: To describe the association between hospital resource utili zation and physicians' knowledge of patient preferences for cardiopulm onary resuscitation (CPR) among seriously ill hospitalized adult patie nts. DESIGN: Prospective cohort study. SETTING: Five U.S. academic med ical centers, 1989-1991. PATIENTS: A sample of 2,636 patients with sel f- or surrogate interviews and matching physician interviews describin g patient preferences for CPR, from a cohort of 4,301 patients with li fe-threatening illnesses enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). MEASU RES: Patient, surrogate, and physician reports of preferences for resu scitation, and resource use derived from the Therapeutic Intensity Sco ring System and hospital length of stay, converted into 1990 dollars. RESULTS: Nearly one-third of the patients preferred to forgo resuscita tion. Of the 2,636 paired physician-patient answers, nearly one-third did not agree about preferences for resuscitation. The physicians' vie ws of the patients' preferences and those preferences themselves were both associated with resource use. Standardized adjusted hospital reso urce consumption, expressed as average cost in dollars during the enro llment hospitalization, was lowest when the physician agreed with the patient preference for a do-not-resuscitate order ($20,527), and highe st when the patient did not have a preference and the physician believ ed the patient wanted resuscitation in the case of a cardiopulmonary a rrest ($34,829). Hospital resource use was intermediate when patient-p hysician pairs evidenced either lack of agreement or communication, or awareness of options about resuscitation. CONCLUSIONS: Both physician and patient preferences for CPR influence total hospital resource con sumption. Physician misunderstanding of patient preferences to forgo C PR was associated with increased use of hospital resources, and could have led to a course of care at odds with patients' expressed preferen ces in the event of cardiac arrest. Increasing physicians' knowledge o f patient preferences, and increasing communication to help patients u nderstand that options for medical care that include forgoing resuscit ation efforts, might reduce hospital expenditures for the seriously il l.