Shared decision making for advanced heart failure has become both more challenging and more crucial as duration of disease and treatment options have increased. High-quality decisions are chosen from medically reasonable options and are aligned with values, goals, and preferences of an informed patient. The top 10 things to know about decision making in advanced heart failure care are listed in Table 1.

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Table 1. 
Top Ten Things to Know



Providers have an ethical and legal mandate to involve patients in medical decisions. Shared decision making recognizes that there are complex trade-offs in the choice of medical care.1 Shared decision making also addresses the ethical need to fully inform patients about the risks and benefits of treatments.2 In the setting of multiple reasonable options for medical care, shared decision making involves clinicians working with patients to ensure that patients' values, goals, and preferences guide informed decisions that are right for each individual patient.

Grounded in the ethical principle of autonomy,3 judicial decisions (eg, Cruzan v Missouri Department of Health 4) and legislative actions (eg, the Patient Self-Determination Act5) have repeatedly affirmed the rights of patients or duly appointed surrogates to choose their medical therapy from among reasonable options.6 The formal process of informed consent before procedural interventions is an embodiment of this concept in that it underscores the clinician's obligation to ensure that the patient has the opportunity to be informed.3 An informed patient is one who is aware of the diagnosis and prognosis, the nature of the proposed intervention, the risks and benefits of that intervention, and all reasonable alternatives and their associated risks and benefits.7 A major purpose of a high-functioning healthcare system is to provide the resources with which an activated, informed patient can engage in productive discussions with a proactive, …

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Decision Making in Advanced Heart Failure A Scientific Statement From the American Heart Association

https://www.wanfang.gov.tw/Upload/WebDownLoadFile1201505141446165.pdf

Efficacy of Advance Care Planning: A Systematic Review and Meta-Analysis

HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. This document was developed in collaboration and endorsed by the American College of Cardiology (ACC), the American Geriatrics Society (AGS), the American Academy of Hospice and Palliative Medicine (AAHPM);

The purpose of this Consensus Statement is to focus on implantable cardioverter-defibrillator (ICD) deactivation in patients with irreversible or terminal illness. This statement summarizes the opinions of the Task Force members, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS), based on ethical and legal principles, as well as their own clinical, scientific, and technical experience. It is directed to all healthcare professionals who treat patients with implanted ICDs, nearing end of life, in order to improve the patient dying process. This statement is not intended to recommend or promote device deactivation. Rather, the ultimate judgement regarding this procedure must be made by the patient (or in special conditions by his/her legal representative) after careful communication about the deactivation's consequences, respecting his/her autonomy and clarifying that he/she has a legal and ethical right to refuse it. Obviously, the physician asked to deactivate the ICD and the industry representative asked to assist can conscientiously object to and refuse to perform device deactivation.

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EHRA Expert Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy

Objective: The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults. Method: Direct interviews of hospitalized and community-dwelling cognitively intact patients .65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives.We identifiedfive variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables. Results: Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p , 0.0002), age (p , 0.0161), race (p , 0.0001), education (p , 0.0039), and religion (p , 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3, p , 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2, p , 0.0001), having undergone major surgery (OR 6.3, p , 0.0017), female gender (OR 11.1, p , 0.0001) and increasing age (76‐85 vs. 59‐75: OR 3.4, p , 0.0543; ,85 vs. 59‐75: OR 6.3, p , 0.0263). Significance of results: This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

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Factors influencing older adults to complete advance directives.

BACKGROUND

No national policy requires health care providers to discuss with hospitalized patients whether the latter would want cardiopulmonary resuscitation (CPR) or mechanical ventilation (MV) in the event of cardiopulmonary failure.



OBJECTIVE

To determine whether hospitalized patients are willing to discuss end-of-life issues and choose whether to receive CPR and MV.



DESIGN

Prospective randomized trial.



PARTICIPANTS

297 patients admitted to the medicine service of a 350-bed community teaching hospital.



INTERVENTION

Patients were randomized to receive routine care or a scripted intervention, delivered by research physicians, that included detailed information about CPR, MV, and advance directives.



MEASUREMENTS

Number of patients who welcomed the scripted intervention, number who chose to receive or reject CPR/MV, and number of advance directives created during hospitalization.



RESULTS

Of the 297 patients studied, 136 were in the intervention group and 161 were in the control group. Baseline characteristics and severity of illness were similar in the 2 groups. Of the 136 patients in the intervention group, 133 (98%) willingly discussed CPR and mechanical ventilation, and 112 (82%) found the information useful. One hundred and twenty-five (92%) clarified their preferences regarding CPR and MV after receiving the intervention; of the 48 patients who were initially documented as wanting CPR/MV, 3 requested no CPR/MV after the intervention. Of the 87 patients in the intervention group who had no documentation of code status on admission, 5 asked for no CPR/MV. Of the 161 patients in the control group, 55 had documentation of their code status on admission. Of the 106 patients without documentation, 6 were later documented to receive no CPR/MV. Thirteen of the 102 patients who had no advance directive on admission created one after the intervention, whereas only 1 of the 128 patients in the control group did so (P < .001).



CONCLUSIONS

Patients are willing to discuss and give informed consent for CPR and mechanical ventilation early in hospitalization. Only a minority drafted advance directives during hospitalization. Larger studies that include patients at other centers are required to determine whether these findings are reproducible and whether this approach is clinically feasible. Journal of Hospital Medicine 2006;3:161–167. © 2006 Society of Hospital Medicine.

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Stavros Mountantonakis

Papers

If asked, hospitalized patients will choose whether to receive life-sustaining therapies.