Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Benefits and harms associated with cardiopulmonary resuscitation in patients with advanced cancers

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

1. Likelihood of successful extubation/rehabilitation in patients undergoing resuscitation in the inpatient setting 2)Patient-level characteristics/variables associated with desirable and undesirable outcomes of resuscitation efforts in inpatients (i.e., can variables be identified for which resuscitation leads to greater harms than benefits)? 3)Survival compared between patients who undergo resuscitation and who choose a DNR status 4)Review of various approaches to code status in inpatient settings and associated outcomes

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients with advanced/metastatic cancers

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Multiple prior lines of treatment; survival estimated <6 months; comorbid conditions; low hgb; high ldh; poor performance status score

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Can patients and provides be better informed about expected outcomes of cardiopulmonary resuscitation based on patient-level characteristics, in order to make better informed decisions about selecting code status options.

Describe any health-related risks, side effects, or harms that you are concerned about.

Potential harms include: pain to the patient; psychological distress to the patient and family; false hope/expectations to the patient and family

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cancer

AHRQ Priority Populations

• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Substantial pain and distress, as well as false expectations may be associated with discussions about inpatient resuscitation. Reduced comfort and dignity at the end of life may result from inadequate information provided to patients, families, and providers about this topic.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

I chair the ASCO clinical practice guidelines committee and participate in a number of efforts to define priority questions in oncology CER. This is an important issue that has come up in multiple prior discussions of stakeholders -- particularly among patient advocates/representatives. Many practitioners do not have adequate information about the benefits vs harms of aggressive resuscitation plans vs DNR, and how to provide evidence to patients to guide informed decisions.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

See above.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Systematic review will inform guideline developers and information disseminated by patient organizations.

Describe the timeframe in which an answer to your question is needed.

ASAP

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Patients without access to reliable healthcare information, low education levels, different primary language spoken from their providers, or a different cultural orientation from their providers, may not understand the issues involved with this complex decision. Decision aids which are patient-centered are needed in this area.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Systematic review will inform guideline developers and information disseminated by patient organizations.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program