Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients

Journal of Critical Care (2009) 24, 280–287

DNR

Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients☆ Khalid F. Almoosa MD a,⁎, Linda M. Goldenhar PhDb , Ralph J. Panos MDc a

Division of Pulmonary, Critical Care, and Sleep Medicine, University of Texas Health Science Center at Houston, Houston, TX 77030, USA b Department of Family Medicine, University of Cincinnati, Cincinnati, OH 45267, USA c Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, OH 45267, USA

Keywords: Cardiopulmonary resuscitation; Decision-making; Surrogate

Abstract Purpose: In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions. Materials and Methods: Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes. Results: Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P b .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5). Conclusions: Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR. © 2009 Elsevier Inc. All rights reserved.

☆

Institutions where work was performed: University of Cincinnati University Hospital, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH. ⁎ Corresponding author. Tel.: +1 713 500 6839; fax: +1 713 500 6829. E-mail addresses: [email protected] (K.F. Almoosa), [email protected] (L.M. Goldenhar), [email protected] (R.J. Panos). 0883-9441/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2009.03.002

1. Introduction Decisions concerning resuscitation are essential components of critical care that affect patients' outcomes and families' perceptions of care [1,2]. In the intensive care unit (ICU), patients are often unable to participate in these

CPR discussions between physicians and surrogates decisions due to illness severity or treatments [3]. Consequently, many cardiopulmonary resuscitation (CPR) discussions and decisions in the ICU occur between healthcare providers and patients' surrogate decision makers [3]. To make appropriate decisions, surrogates must be knowledgeable about the patients' clinical condition and prognosis, the procedures, role, and feasibility of CPR [4,5], and the patients' wishes regarding resuscitation and other lifesustaining therapies. Unfortunately, most patients have neither documented nor expressed their preferences for CPR to family members or caregivers [6]. Consequently, many surrogates rely heavily on information received during discussions with ICU physicians [1,7], making the content and perception of these discussions critical to their decision making process. Few studies have evaluated the characteristics of CPR discussions between ICU physicians and surrogates of critically ill patients. Prior investigations studied the patients directly [8-10], focused on terminally ill patients [10,11], involved nonintensivists [8-11], or included outpatients or non-critically ill inpatients [10,11]. These studied reported that communication between physicians and patients was poor and less than half discussed CPR preferences [8]. Most of these seriously ill patients and their caregivers had poor knowledge of CPR, including its components and success rates [9]. One study by Curtis et al [12] described the types of communication and support offered during discussions about CPR between physicians and critically/terminally ill patients' family members but did not examine the content or the surrogates' perceptions of these discussions. Therefore, to better understand the interaction between physicians and patients' surrogates regarding CPR, we studied the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogate decision makers and ICU physicians.

2. Materials and methods 2.1. Study design This prospective 2-center observational study was performed in the medical ICUs of the University of Cincinnati University Hospital (18 beds) and the affiliated Veterans Affairs Medical Center (12 beds) from September 2006 to August 2007. Both ICUs are “closed” and staffed with an ICU team composed of 1 critical care attending, 1 fellow, and 4 to 5 internal medicine residents (postgraduate year 1-3). All CPR discussions were performed by the residents or fellows.

2.2. Patients and surrogates Study criteria were defined for both patients and surrogates. Patient inclusion requirements were: (1) an

281 admission Acute Physiology And Chronic Health Evaluation II score of 16 or higher, (2) ICU stay 24 hours or longer, and (3) an available surrogate willing to participate in medical decisions. Patients were excluded if they (1) were mentally competent and had decision-making capacity; (2) had a valid, written, legal document expressing their resuscitation wishes; or (3) had life-sustaining therapy withdrawn and death was imminent. Surrogate inclusion criteria included (1) age 18 years and above and (2) designation as the healthcare decision-maker in the medical record or the State of Ohio legal hierarchy of acceptable surrogates. All consecutive patients admitted to the ICU were screened daily for study eligibility. Eligible subjects' surrogates were identified through the patient's medical record or advance directives if available and approached by ICU research staff. If surrogates were not available at the bedside, attempts at telephone contact were made twice each day until contact was established or the patient was discharged from the ICU. In-person surrogate interviews were conducted by research staff in a private family conference room, and phone interviews were conducted with surrogates who could not be interviewed in person. Each patient's medical record was reviewed for pertinent information and monitored throughout the patient's ICU stay.

2.3. Questionnaire development We abstracted relevant questions from previously validated instruments and developed new questions to create the questionnaire used in this study (Appendix E1). To answer our research question, we measured a number of critical content domains, including patient and surrogate demographics, discussion content and logistics, surrogates' understanding and perceptions of the discussion, and satisfaction with the discussion. Specific responses to questions were provided to subjects and included a variety of scales. To assess content and face validity, an initial set of questionnaire items underwent review by 4 experts, and changes were made based on their feedback. The questionnaire was then pretested on 9 subjects who met eligibility criteria. The final questionnaire was written at the 7.5 grade level. To confirm data accuracy, information from 16 randomly selected questionnaires was compared with the original data entered into the database. Data entry was confirmed to be accurate (N90%) and complete (N95%).

2.4. Data analysis Using 50% as the estimated prevalence of discussions (primary outcome variable), a power (1 − β) of 0.8 and an α of .05, the required sample size determined by χ2 analysis was 86. All data were entered into a Microsoft Excel

282

K.F. Almoosa et al.

database (Microsoft Corporation, Redmond, WA). Mean, standard deviation, and 95% confidence intervals were calculated. Categorical variables were analyzed as frequencies or proportions. In addition to descriptive analyses, correlations, multivariable logistic regression and crosstabulation analyses comparing “discussion” and “no discussion” groups were performed. All significant differences are defined as P b .05; SAS 9.1.3 (copyright 2002-2003; SAS Institute, Cary, NC) was used for all statistical analyses.

2.5. Research ethics The study protocol and questionnaire were approved by the University of Cincinnati Institutional Review Board and

Table 1

the Veterans Affairs Research and Development Committee. Informed consent was obtained from all subjects.

3. Results 3.1. Patient and surrogate demographics Patients' and surrogates' clinical and demographic characteristics were similar whether or not a CPR discussion occurred (Table 1). Most surrogate interviews (65%) were conducted in person 4.9 ± 4.5 days (mean + SD) after the patient's ICU admission. Telephone interviews were performed when surrogates were not present in the ICU. There

Patient and Surrogate Demographics

Patients Age (y) Mean ± SD Range Sex (% male) Ethnicity (% white) APACHE score mean ± SD Source of admission Emergency department Ward Other ICU or hospital Admitting diagnoses (% of total) Sepsis or infection Respiratory failure Non-respiratory organ failure Drug overdose or metabolic disorders Code status on admission (% full) Recent hospitalization in past 6 mo (% yes) Presence of terminal illness (% yes) ICU stay at time of research interview (d) Mortality Surrogates Age (y) Mean ± SD Range Gender (% male) Ethnicity (% white) Highest level of education Some or no high school Completed high school College graduate Relationship to patient Spouse Adult child Parent Other

All patients (n = 84)

Discussion (n = 45)

No discussion (n = 39)

63 ± 16 27 to 89 69% 58% 23 ± 6

67 ± 14 29 to 89 73% 58% 24 ± 7

59 ± 16 ⁎ 27 to 88 64% 59% 22 ± 6

61% 23% 16%

57% 27% 16%

66% 18% 16%

39% 48% 29% 17% 83% 68% 23% 4.9 ± 4.5 24%

47% 47% 36% 13% 80% 70% 24% 5.1 ± 5 37%

30% 49% 22% 22% 85% 66% 23% 4.6 ± 4 8% ⁎

53 ± 14 22 to 84 30% 57%

53 ± 14 22 to 81 24% 53%

52 ± 15 26 to 84 36% 62%

11% 70% 20%

7% 73% 20%

16% 65% 19%

35% 38% 15% 12%

36% 44% 9% 11%

33% 31% 23% 13%

APACHE indicates Acute Physiology And Chronic Health Evaluation. Terminal illness is any chronic illness with an expected survival of 6 months or less. ⁎ P b .05 compared with discussion group.

CPR discussions between physicians and surrogates Table 2

Characteristics of CPR Discussions

Surrogates who had discussions with doctors (%) Length of discussion (mean ± SD; min) Others present during the discussion (% yes) % of discussions occurring within 24 h of ICU admission % of surrogates who had N1 CPR discussion with physicians Place of discussions Patient's room Other private room Public areas (hallway, waiting room, ED) Over the phone

54% 16 ± 14 62% 78% 56%

44% 9% 31% 18%

283 most (35/39; 90%) were not given nor did they pursue the opportunity to discuss CPR, although most (22/37; 59%) said they would have wanted to discuss resuscitation (Fig. 1). Of the core components of CPR (chest compressions, electrical cardioversion, and endotracheal intubation with mechanical ventilation), most of the surrogates (34/45; 73%) recalled discussing endotracheal intubation with mechanical ventilation, and most (27/32; 84%) said they understood what it entailed (Fig. 2). Although a smaller proportion remembered discussing chest compressions (21/45; 47%) or electrical cardioversion (19/45; 42%), most of these surrogates (68%-70%) also reported good understanding. Only 29% (13/45) recalled discussing all three components.

ED indicates Emergency department.

3.3. Surrogates' perceptions of discussions were no significant differences in discussion characteristics between the in-person and telephone interview groups.

3.2. Discussion logistics and content Of 84 surrogates, 45 (54%) had CPR discussions with ICU physicians, and most conversations (35/45; 78%) occurred within 24 hours of the patients' ICU admission (Table 2). Physicians initiated most (36/45; 80%) CPR discussions. Over half of the surrogates (25/45; 56%) participated in more than 1 discussion. Surrogates estimated that the duration of the initial CPR discussion was 16 ± 14 minutes (range, 5-60 minutes). Most discussions (37/45; 82%) were conducted in-person between the physician and surrogate, and 62% (28/45) occurred with another family member or friend present. For the surrogates who did not participate in a CPR discussion (39 of 84 subjects; 46%),

Surrogates experienced high satisfaction with the CPR discussions (Fig. 3). Most (36/43; 84%) stated that their questions were mostly or entirely answered and that the discussions facilitated making a CPR decision (33/42; 77%). Most surrogates (40/45; 89%) believed the physicians were “telling them everything about the patient's condition.” Very few (7/44; 16%) responded that the physicians actually suggested a specific decision, and only 1 surrogate believed the physician “forced” her to make a decision. When asked if they preferred the physician to make the resuscitation decision for them, 90% (36/40) said no.

3.4. Patients' outcomes One quarter (25%) of surrogates changed the patient's resuscitation decision (ie, “code status”) to a less aggressive

Fig. 1 Responses of surrogates who did not participate in CPR discussions. Most were not asked or given an opportunity to discuss the patient's resuscitation options, although most wanted to.

284

K.F. Almoosa et al.

Fig. 2 Occurrence and understanding of core components of CPR discussions with surrogates of ICU patients. Surrogates recalled endotracheal intubation being discussed most often. Good understanding was reported for all 3 components when discussed.

preference after discussing CPR. However, 18% of surrogates who had not had a CPR discussion at the time of the study interview changed to a less aggressive resuscitation level during the patient's ICU course (P = .5). Changes in resuscitation status occurred 6.6 ± 6.5 days (mean ± SD) after ICU admission in the CPR discussion group and 7.4 ± 3.2 days in the no-discussion group (P = .7).

All changes resulted in a “do not resuscitate” decision from an initial “full resuscitation” status. The sample size was too small to perform correlations between changes in resuscitation status and the surrogates perceptions and satisfaction with the discussions. Patient mortality was higher in the group that participated in discussions (37% vs 8%, P b .05).

Fig. 3 Perceptions of CPR discussions by surrogates. Most surrogates were satisfied with the discussions and felt making a decision was consequently easier. Nevertheless, a sizeable proportion wanted to have another discussion, and only a few had changed their CPR preferences.

CPR discussions between physicians and surrogates

4. Discussion Among two academic medical centers, CPR discussions between physicians-in-training and surrogates occurred for only 54% of ICU patients without decision-making capacity. Most (80%) discussions were initiated by physicians and more than one discussion occurred for 56% of patients. Although most surrogates felt they understood the components of CPR, mechanical ventilation was remembered more often than chest compressions or cardioversion. Most surrogates were satisfied with these discussions and almost all regarded the interaction positively. Patient mortality was higher in the group that participated in discussions. Approximately half of the surrogates of ICU patients unable to make resuscitation decisions recalled having had a CPR discussion with physicians. Ten years ago, Hofmann et al [13] reported that less than 25% of critically ill patients participated in CPR discussions. A more recent study of elderly non-ICU hospitalized patients with advanced medical conditions or cancer and their surrogates found that only 34% had discussed CPR [9]. The increased frequency of CPR discussions in our study may reflect increasing awareness and openness about end-of-life discussions or differences between patients' and surrogates' willingness to discuss CPR. There were no differences in patients' or surrogates' age, sex, ethnic background, education level, or severity of the patient's illness between the discussion and no discussion groups that may have affected the selection of discussion participants. In contrast, Hofmann et al [13] identified several patient-specific factors, including ethnicity, absence of advance directives, excellent prognosis, good quality of life, and lack of a desire to participate in medical decisions that were independently associated with patients not participating in CPR discussions. Physicians' personal beliefs and preferences about end-of-life care may also affect the likelihood of having a CPR discussion. Some studies have reported significant physician discomfort and internal conflict in initiating these discussions [14-16]. The role of physicians-in-training and their experience and education in CPR discussions may also have influenced our findings. Most of the CPR discussions were initiated by physicians, confirming prior reports that physicians are the main initiators of discussions about resuscitation [17,18] and that most patients and families prefer them to assume this role [19-21]. In fact, failure of physicians to initiate discussion on end-of-life care is a significant barrier to identifying patients' end-of-life preferences [22]. On the other hand, a significant proportion of surrogates in the no discussion group were not interested in speaking with the ICU physicians about CPR, confirming similar reports by Hofmann et al [13] and Heyland et al [9] that demonstrated 37% to 58% of patients were not interested in having a CPR discussion. Finally, some of the surrogates who indicated they did not have a CPR discussion may have had one after the study interview or may not have remembered the conversation about CPR.

285 Less than one third of surrogates remembered discussing the three core components of CPR: chest compressions, electrical cardioversion, and endotracheal intubation [23,24]. However, when recalled, most surrogates felt they understood most or all of what was said. Few studies have reported how often these specific components are discussed during or recalled from conversations about resuscitation [14,16]. Fischer et al [25] interviewed 56 primary care outpatients after conversations about lifesustaining treatments and reported that only 43% could identify two important characteristics of resuscitation and 26% identified none. They also found that none of the patients who discussed mechanical ventilation understood it well and 46% had serious misconceptions about ventilators. Improved understanding of resuscitation methods may better inform patients and surrogates and assist in their CPR decision making process. In our study, surrogates recalled discussions about intubation and mechanical ventilatory support more frequently than either chest compressions or electrical cardioversion. This is not surprising, as endotracheal intubation, in contrast to the other interventions, is not limited to those suffering a cardiopulmonary arrest. It is also possible that either physicians or surrogates perceived mechanical ventilation as a supportive maneuver whereas chest compression and electrical cardioversion were resuscitative therapies. The failure of most surrogates to recall the core components of CPR suggests that the clarity and/or content of these discussions is suboptimal, potentially rendering surrogates ineffective in making a CPR decision. In addition, although our study did not address surrogates' recollections and understanding of other components of CPR, such as its risks, benefits, outcomes, and alternatives, these factors may affect the utility and quality of CPR discussions and ultimately CPR decisions. Finally, CPR discussions increasingly include a “menu” of options in addition to the three core components. Although this approach was not examined in this study, future efforts to assess the comprehension of specific components of CPR discussions and the use of this approach may further enhance our understanding of the endof-life decision-making process. Despite surrogates' poor recollections of the core components of CPR, most perceived the CPR discussions positively. Most reported that most or all of their questions were answered, that most physicians were “telling them everything about the patient's condition,” and that the discussions made it “easier to decide what to do” if the patient required CPR. Because we did not objectively examine the discussions for content or have a standardized approach to CPR discussions, the actual content of the conversations may have varied and we cannot confirm the accuracy of these perceptions. Furthermore, because surrogates may initially have very little knowledge of CPR, high satisfaction may result from the exchange of any information or the mere occurrence of communication between physicians and surrogates rather than from the quality of the

286 interaction [9,26]. Finally, because surrogates are unlikely to confirm or question the accuracy of information given by the physician, satisfaction cannot be correlated with the quality or content of these discussions. Most surrogates also felt that the physicians did not suggest or force them into making any specific CPR decision; whether this reflects honest objectivity by physicians or a failure to guide surrogates through the difficult CPR decision-making process was not determined in this study and warrants further examination. Mortality was higher in the group that participated in a CPR discussion (37% vs 8%, P b .05), despite the same frequency of changes in resuscitation status, clinical characteristics, and disease severity in both groups. It is possible, however, that the sample size was too small to distinguish true differences in these variables or that other unmeasured factors prompted CPR discussions in patients with higher mortality. The strengths of this study include its prospective, multicenter design and its adequate sample size based on robust power analysis. Furthermore, this is a relatively unexplored area in need of further study, and our data provide information in a select group of patients that has not been reported in the literature. Finally, our results offer new areas and questions in need of further investigation. We addressed study limitations in several ways. First, many of the survey questions relied on surrogates' recall of the CPR discussion. To minimize the potential for recall bias, we attempted to conduct interviews early in the patients' ICU stay and soon after the CPR discussion would have occurred. Second, more than 1 CPR discussion may have occurred over the course of the patient's stay and may have differed in structure and content. We asked the surrogates to respond to the questions based upon their recollection of the initial discussion, as it is often when the most time is spent discussing CPR and an initial impression and understanding of CPR are formulated. Third, we did not survey the physicians' perspectives on the CPR discussions. Because the physicians in this study were “in-training,” limited experience and knowledge of CPR and end-of-life decision-making may affect surrogates' perceptions and understanding, although some studies have shown little difference between trainees and practicing physicians in some clinical parameters [27-29]. Finally, many of our patients did not have surrogates readily available. To avoid selection bias, multiple attempts were made to contact all eligible subjects throughout the patient's ICU stay. In summary, only half of critically ill patients' surrogates participated in CPR discussions and less than one third recalled all core components of resuscitation, but the overwhelming majority felt they understood the CPR process very well and were satisfied with the resuscitation discussions. For surrogates as well as physicians who do not participate in CPR discussions, further research is needed to determine why this essential communication does not occur. A better understanding of the interaction between physicians

K.F. Almoosa et al. and patients' surrogates is necessary to improve resuscitation discussions in the ICU.

Acknowledgment The authors thank Emily Werff and Maria Reinert for their efforts in this study.

Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jcrc.2009.03.002.

References [1] Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA. Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med 2001;29(1):197-201. [2] Prendergast TJ, Puntillo KA. Withdrawal of life support: intensive caring at the end of life. JAMA 2002;288(21):2732-40. [3] Prendergast TJ, Luce JM. Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 1997;155(1):15-20. [4] Hall RI, Rocker GM. End-of-life care in the ICU: treatments provided when life support was or was not withdrawn. Chest 2000;118(5):1424-30. [5] Way J, Back AL, Curtis JR. Withdrawing life support and resolution of conflict with families. BMJ (Clin Res Ed) 2002;325(7376):1342-5. [6] Cook DJ, Guyatt G, Rocker G, Sjokvist P, Weaver B, Dodek P, et al. Cardiopulmonary resuscitation directives on admission to intensivecare unit: an international observational study. Lancet 2001;358 (9297):1941-5. [7] Smedira NG, Evans BH, Grais LS, Cohen NH, Lo B, Cooke M, et al. Withholding and withdrawal of life support from the critically ill. N Engl J Med 1990;322(5):309-15. [8] 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). The SUPPORT Principal Investigators. JAMA 1995;274(20):1591-8. [9] Heyland DK, Frank C, Groll D, Pichora D, Dodek P, Rocker G, et al. Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members. Chest 2006;130(2):419-28. [10] Schwartz CE, Wheeler HB, Hammes B, Basque N, Edmunds J, Reed G, et al. Early intervention in planning end-of-life care with ambulatory geriatric patients: results of a pilot trial. Arch Intern Med 2002;162(14):1611-8. [11] Johnston SC, Pfeifer MP. Patient and physician roles in end-of-life decision making. End-of-Life Study Group. J Gen Intern Med 1998;13 (1):43-5. [12] Curtis JR, Engelberg RA, Wenrich MD, Nielsen EL, Shannon SE, Treece PD, et al. Studying communication about end-of-life care during the ICU family conference: development of a framework. J Crit Care 2002;17(3):147-60. [13] Hofmann JC, Wenger NS, Davis RB, Teno J, Connors Jr AF, Desbiens N, et al. Patient preferences for communication with physicians about end-of-life decisions. SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment. Ann Intern Med 1997;127(1):1-12.

CPR discussions between physicians and surrogates [14] Deep KS, Green SF, Griffith CH, Wilson JF. Medical residents' perspectives on discussions of advanced directives: can prior experience affect how they approach patients? J Palliat Med 2007;10 (3):712-20. [15] Marik PE, Varon J, Lisbon A, Reich HS. Physicians' own preferences to the limitation and withdrawal of life-sustaining therapy. Resuscitation 1999;42(3):197-201. [16] Sullivan KE, Hebert PC, Logan J, O'Connor AM, McNeely PD. What do physicians tell patients with end-stage COPD about intubation and mechanical ventilation? Chest 1996;109 (1):258-64. [17] Balaban RB. A physician's guide to talking about end-of-life care. J Gen Intern Med 2000;15(3):195-200. [18] Collins N, Phelan D, Marsh B, Sprung CL. End-of-life care in the intensive care unit: the Irish Ethicus data. Crit Care Resusc 2006;8 (4):315-20. [19] Heffner JE, Fahy B, Hilling L, Barbieri C. Attitudes regarding advance directives among patients in pulmonary rehabilitation. Am J Respir Crit Care Med 1996;154(6 Pt 1):1735-40. [20] Lo B, McLeod GA, Saika G. Patient attitudes to discussing lifesustaining treatment. Arch Intern Med 1986;146(8):1613-5. [21] Sahm S, Will R, Hommel G. What are cancer patients' preferences about treatment at the end of life, and who should start talking about it? A comparison with healthy people and medical staff. Support Care Cancer 2005;13(4):206-14.

287 [22] Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care–a case for greater use. N Engl J Med 1991;324(13):889-95. [23] Cooper JA, Cooper JD, Cooper JM. Cardiopulmonary resuscitation: history, current practice, and future direction. Circulation 2006;114 (25):2839-49. [24] Ali B, Zafari AM. Narrative review: cardiopulmonary resuscitation and emergency cardiovascular care: review of the current guidelines. Ann Intern Med 2007;147(3):171-9. [25] Fischer GS, Tulsky JA, Rose MR, Siminoff LA, Arnold RM. Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med 1998;13(7):447-54. [26] Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med 1996;334 (24):1578-82. [27] Lee WN, Langiulli M, Mumtaz A, Peterson SJ. A comparison of humanistic qualities among medical students, residents, and faculty physicians in internal medicine. Heart Dis (Hagerstown, Md) 2003;5 (6):380-3. [28] Donofrio MT, Barron DM, Winters SL, Gomes JA, Gorlin R. Cardiopulmonary resuscitation: qualifications and performance of housestaff and trained internists. Mt Sinai J Med N Y 1989;56(4):279-84. [29] Mehall JR, Shroff S, Fassler SA, Harper SG, Nejman JH, Zebley DM. Comparing results of residents and attending surgeons to determine whether laparoscopic colectomy is safe. Am J Surg 2005;189(6):738-41.