The decision whether to receive cardiopulmonary resuscitation (CPR) is a decision in which the personal values of the patient must be considered along with information about the risks and benefits of the treatment. A decision aid can be used to provide patient decision support to a patient who is seriously ill and needs to consider CPR options. The goal of this project was to identify the barriers and facilitators to using a CPR decision aid, through evaluating nursing perceptions on providing patient decision support. Using a needs assessment, it was determined that implementing a patient decision aid for CPR status in the Acute Monitor Area (AMA) of The Ottawa Hospital would be an excellent quality improvement project. The nurses who chose to participate were given an education session regarding patient decision support. Questionnaires were distributed to evaluate their views of patient decision support and decision aids before and after the education session and implementation of the CPR decision aid. Questionnaire results did not indicate a significant change between before or after education session and decision aid implementation. Qualitative reports did indicate that nurses generally have positive attitudes toward patient decision support and decision aids. The nurses identified specific barriers and facilitators in their commentaries. This clinically relevant data supports the idea that patient decision support should be integrated into daily nursing practice.
Improving informed decision making is essential for supportive end of life care [
CPR preferences may also be overlooked or set aside by practitioners because it is a value-sensitive decision or because it is not identified as a high priority discussion [
CPR status is one of the most important health decisions and requires careful consideration of all alternatives and the consequences. For seriously ill patients, CPR preferences are commonly set aside and communication between the patient, family, and health care team is lacking information and followup [
This project took place at The Ottawa Hospital, Acute Monitor Area (AMA) Unit. This six-bed unit specializes in acute care, managing patients with a variety of complex medical conditions such as chronic obstructive pulmonary disease, congestive heart failure, pneumonia, and multisystem failure disorders.
The goal of this project was to implement a publically available patient decision aid for CPR status and to identify any factors which limit or encourage its use [
A literature review was conducted to identify scholarly English publications pertaining to “cardiopulmonary resuscitation preferences,” “end of life treatment,” “patient decision support,” “decision making,” and “patient decision aids” in PubMed, PsycINFO, CINAHL, Proquest Nursing and Allied Health, and the Cochrane Database of Systematic Reviews. Notable articles were screened by reviewing their reference lists for relevant publications. Grey literature searches were also conducted through the Registered Nurses’ Association of Ontario (RNAO), College of Nurses of Ontario (CNO), and the Ottawa Hospital Research Institute (OHRI) websites.
It has been identified by Heyland and colleagues [
It has been determined that seriously ill patients have poor knowledge about what CPR entails and their role in the decision making process regarding their CPR status [
The literature on patient decision support has increased a great deal since O’Connor and colleagues published their work in 1998 [
Decisional conflict means that there is uncertainty about which course of action to take [
Patient decision aids are a part of providing decision support. They are ‘‘tools that help people become involved in decision making” [
Facilitation of nurse involvement in end of life care is essential for comprehensive care. However, shared decision making has not been embraced by all health professionals and barriers have been identified which limit the use of patient decision aids [
The Ottawa Decision Support Framework ODSF (1998) developed by Annette O’Connor and colleagues guided this project. This concrete, midrange theory focuses on decisional needs, decision quality, and decision support. It can guide gaining decision support skills through a practical and structured approach [
The main assumption of the ODSF is that patients will likely select the choice that they believe is their best alternative which aligns with their personal values [
Patient decision support is provided through counselling, coaching, and decision aids [
Decision support is provided until decisional conflict is resolved and a quality decision is reached. Then aiding implementation and monitoring of the decision occur [
Specifically, the ODSF guided this project to address unmet decisional needs or decisional conflict where uncertainty regarding the best choice for CPR status was identified in seriously ill patients. Realistic expectations were discussed, evidenced-based information was reviewed, support and resources were appraised, and patient values were considered [
Ethical approval for this project was obtained from The Ottawa Hospital Research Ethics Board. Consent was obtained from each participant and information regarding the project was provided. The intervention design involved three steps including (1) conducting a pretest, (2) educating the nurses on patient decision support and the CPR decision aid, and (3) conducting a posttest.
It was identified during discussions with nurses who work in the AMA and their nurse educator (the project advisor) that frequently a patient’s CPR status is not addressed in a timely manner. It was repeatedly suggested that an improvement needs to be made to address the patient’s information and communication needs regarding CPR status. The discussions lead to an intervention focused on influencing nursing knowledge of patient decision support, uptake of a CPR decision aid, and identifying facilitators and barriers to its use [
Initially, an advertisement of the educational intervention was posted. All registered nurses who work in the AMA unit were approached to participate in the education session. Due to time constraints and that there were other quality improvement initiatives being implemented concurrently, it was decided that only a brief and basic education session would be offered. The education session consisted of an introduction to why the project was being implemented, what patient decision support is, and an overview of the CPR patient decision aid. Taking approximately 5–10 minutes, nurses were guided individually or in small groups through part one of the Ottawa Decision Support Tutorial, ODST [
After having received the education, the nurses were requested to provide patient decision support for CPR preference using the patient decision aid based on clinical opportunities and appropriateness [
Each Ottawa Hospital form for code status was affixed with the CPR decision aid to prompt each nurse to its use. Nurses were advised that if a CPR decision aid was initiated and/or completed they were to write in the interprofessional progress notes in the patient’s medical record of this. It was also asked that this information should be communicated to other team members in the patient’s daily care plan.
Both qualitative and quantitative measures were used to collect information. Before and after intervention questionnaires were the primary means of information collection. There were no pretested measurement tools found that fit the objectives of this project. Consequently, the questionnaires developed were influenced by a study conducted by Stacey and colleagues [
The questionnaires were designed to be clear and concise using a five-point Likert scale to encourage the participation in attaining data [
Qualitative observations and field notes were routinely collected in a designated journal. These observations were analyzed for recurring themes and notable results. Specifically responses were grouped into one of two categories, facilitators or barriers, and were grouped after each batch of questionnaires was received. Qualitative reports were used to gather data on the impacts on practice and participant’s views on the project which may not be captured with the questionnaires [
Questionnaires were given to all AMA nurses who signed consent and agreed to participate in the project immediately before each education session. Then the education session was given. The after intervention questionnaires were given after six weeks of the first education session. All nurses had an average of five weeks or more to use the patient decision aid. All participants who agreed to complete the post questionnaire were entered into a draw for two gift baskets. Descriptive statistic methods were used to analyze questionnaire responses and content analysis was used in reviewing the qualitative reports [
There are currently 26 nurses who are trained to work in the AMA. Of those nurses, 3 were on maternity leave, 2 declined to participate and 21 agreed to take part in the educational session and before intervention questionnaire (
Not all nurses who initially agreed to take part in the project continued their participation. Sixteen agreed to participate in the after intervention questionnaire (
Participants were asked to rate how strongly they agree or disagree with certain statements. Table
Before CPR patient decision aid questionnaire results.
Statements | Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly agree |
---|---|---|---|---|---|
Most patients prefer to make decisions on their own | — | 6 (29%) | 1 (5%) | 12 (57%) | 2 (9%) |
Most patients prefer to make decisions withothers | — | — | — | 20 (95%) | 1 (5%) |
Most patients prefer to make decisions after considering their health care team’s opinions | — | — | 4 (19%) | 15 (71%) | 2 (9%) |
Patient decision support will increase patient involvement in making health decisions | — | — | 3 (14%) | 15 (71%) | 3 (14%) |
Nurses generally feel confident about providing patient decision support | 1 (5%) | 4 (19%) | 8 (38%) | 8 (38%) | — |
Nurses understand patient decision support concepts | — | — | 4 (19%) | 16 (76%) | 1 (5%) |
Nurses need to increase their knowledge of decision support | — | 1 (5%) | 1 (5%) | 14 (67%) | 5 (24%) |
Nurses need to enhance their ability to provide patient decision support | — | — | 2 (9%) | 16 (76%) | 3 (14%) |
There should be more education on patient decision support/aids | — | — | — | 16 (76%) | 5 (24%) |
I feel more education on patient decision support/aid would benefit the patient | — | — | — | 16 (76%) | 5 (24%) |
After CPR patient decision aid questionnaire results.
Statements | Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly agree |
---|---|---|---|---|---|
Most patients prefer to make decisions on their own | — | 4 (25%) | 2 (13%) | 8 (50%) | 2 (13%) |
Most patients prefer to make decisions withothers | — | — | 2 (13%) | 7 (44%) | 7 (44%) |
Most patients prefer to make decisions after considering their health care team’s opinions | — | — | 1 (6%) | 13 (81%) | 2 (13%) |
Patient decision support will increase patient involvement in making health decisions | — | — | 2 (13%) | 8 (50%) | 6 (38%) |
Nurses validate patient’s values when providing patient decision support | — | — | 3 (19%) | 12 (75%) | 1 (6%) |
Patients should be referred to a specialized nurse educated in decision support | — | — | 5 (31%) | 10 (63%) | 1 (6%) |
Nurses generally feel confident about providing patient decision support | — | 2 (13%) | 8 (50%) | 6 (38%) | — |
The patient decision aid is a good resource (e.g., easy to understand, or nonbiased) | — | — | 2 (13%) | 13 (81%) | 1 (6%) |
The decision aid was easily applied to the clinical setting | — | 1 (6%) | 7 (44%) | 8 (50%) | — |
There was clear direction in providing patient decision support to patients with the CPR decision aid | — | 1 (6%) | 6 (38%) | 9 (56%) | — |
Nurses prefer to have a clear step-by-step approach when supporting patients on deciding CPR status | — | 2 (13%) | 3 (19%) | 10 (63%) | 1 (6%) |
The decision aid made it easier for nurses to identify patients having difficulty in making a CPR choice | — | — | 4 (25%) | 12 (75%) | — |
Overall, I feel that patient decision support/aids for CPR status is useful | — | — | 3 (19%) | 10 (63%) | 3 (19%) |
The following points were recognized in the questionnaire and field note results for facilitators/benefits to patient decision support and aids: a team understanding of the patient condition and status, better communication, a standardized way to present information and a knowledge tool for nurses, supported by the literature, evidenced-based information, clear understanding of what CPR is and the risks/benefits, support for when patient is not able to make their own decision (family involved).
The following points were recognized in the questionnaire and field notes results for barriers/limitations to patient decision support and aids: language barriers, cultural difference, not appropriate for all, family conflict, their lack of understanding or misconceptions, available time to discuss with patient and family, patient not emotionally ready for discussions, patient decision aid was too condition specific; too rigid, patients/families not accepting nursing support on this (not their role).
Many nurses commented that they had limited opportunities to use the patient decision aid for CPR, but did identify that they used patient decision support for other issues. Specifically, some nurses commented on identifying decisional conflict and validating patients’ values. A few nurses stated that CPR status should be determined on admission to hospital and be completed routinely for all patients. There were varied views regarding evaluating CPR status on admission versus at a time of health crisis. Some said it should be addressed for every patient, despite health status, and some indicated that only when death may be imminent it should be discussed. Some nurses stated that they did not see this as a part of their role or something that they wish to partake in. Others thought that this was completely within the nursing realm and were eager to support patients with making an informed CPR choice. Most nurses agreed with the components of a shared decision making model.
After reviewing the data collected it was evident that most nurses were willing to use the patient decision aid because they see it as helping the patient make informed, value-based decisions. The findings were consistent with the literature [
Specific barriers to providing patient decision support were identified as cultural or language influences, time constraints, rigid application, patient’s emotional adversity, and physician preference for this role. These mirror what has been found in the literature [
Data were collected from self-report and observations, not from a validated tool; thus obvious sources of bias were present. The information collected was helpful in this specific clinical setting but cannot be generalized to others. Time was also a limiting factor. There were only six weeks where the patient decision aid was implemented and the opportunity for its use did not come readily. Most nurses welcomed this intervention but some were obviously stressed at the fact that they were approached to participate as evidenced by their body language and facial expressions. This intervention was not the only quality improvement project being initiated. This project may have been better received during a less demanding time for nurse involvement.
This project identified that CPR status specifically can be appraised by a nurse to be a difficult topic, too patient specific to use a patient decision aid, or confident that this would be used as a guide to improve patients’ knowledge of options and the provision of support. CPR status is value-sensitive topic, but it is not beyond what normally would be encountered by a practicing nurse. Addressing unclear values, information needs, and resources effectively will reduce nursing contributing factors to clouding difficult decisions [
Based on this quality improvement project, a practice change towards supporting patients to be more educated and involved in their decision making is a priority. Since nurses work in close proximity with the patient and their families and spend much time involved in their care, they are the most appropriate professionals to discuss CPR preferences using a shared-decision making model [
Challenging the barriers to implementing patient decision support and enhancing the facilitating factors will eventually disclose the benefits of its use. This project identified some of those factors within the Acute Monitor Area at The Ottawa Hospital. Dedication and commitment to supporting patient decision support and the cardiopulmonary resuscitation decision aid will help to support patients facing these difficult situations.
The author thanks Dr. Darren Heyland.