a âDo Not Resuscitateâ order had been written, or unless they were found dead with rigor mortis. They were identified retrospectively far the years. 1 983 to 1 986.
Outcomes
of Cardiopulmonary
Resuscitation
in Dialysis
1,2 Alvin
H. Moss,3
Jean
L. Holley,
and
Matthew
B. Upton were
A.H.
Moss.
Virginia
for
Health
Health
University
town, A.H.
Center
Ethics
and
Sciences
Law,
Center,
unit
West
rarely
Moss,
MB.
Upton,
Department
of
J.L. Holley, Division,
Department University
Pittsburgh,
Pittsburgh
Nephrol.
ABSTRACT Patients with poor survival tion, but there outcomes of alysis patients. patients and perience
1992;
of
Medicine,
the
cardiopulmonary
patients
eight-year
ex-
resuscitation
at a university
dialysis
in di-
program
was
analyzed and outcomes were compared with those of a control group of nondialysis patients undergoing cardiopulmonary resuscitation during the same time period in the same hospital. Of 221 dialysis patients experiencing cardiopulmonary arrest, 74 (34%) had CPR compared with 247 (21%) of 1,201 control patients
(P
=
interval, pital
0.0002).
Six of 74 (8%;
2 to 14%)
discharge
dialysis
95%
patients
compared
with
confidence
survived
30 of 247
to hos(12%;
95%
confidence interval, 8 to 16%) control patients not significant). At 6 months after CPR, 2 (3%)
(P
dialysis
95%
=
of 74 dialysis patients were still alive compared with 23 (9%) of 247 controls (P = 0.044); this difference was not explained by age or comorbid conditions. Twenty-one (78%) of the 27 successfully resuscitated
I 2
patients
Received Presented
Baltimore.
Correspondence
Virginia
a mean
of 4.4
April 14, 1992. Accepted July 20, 1992. In part at the annual scientific meeting
Nephrology. 3
died
University
MD, November
to Dr. A. H. Moss, Health
scIences
later;
of the AmerIcan
center.
in an intensive It was
care
concluded
that
cardiopulmonary
patients,
resuscitation
nephrologists
should
provide
1354
Survival,
advance
directives,
decision
making
5oclety
nly 1 5% of all patients who undergo cardlopulmonary resuscitation (CPR) survive to hospital discharge ( 1 ). Survival after CPR for selected groups of patients such as elderly nursing home residents and those with metastatic cancer is much worse (24). PhysicIans have been encouraged to Inform such patients of their likely poor outcomes after CPR and to refrain from offering It to them (2,4,5). The Information In the medical literature about outcomes of resuscitation in patients with renal fallure Is limited (6- 1 2). However, the available studies suggest that 1 0% or fever of renal failure patients undergoing CPR survive to hospital discharge. Data on CPR outcomes in dialysis patients are even more limited; in one small study, 2 of 1 0 peritoneal dialysis patients left the hospital alive after CPR (1 3). NIne of these patients had major complications of the CPR; five had flail chests, and four had multiple rib fractures. We know that the attitudes of hemodlalysis patients toward CPR do not differ from those of other patients (1 4). Unfortunately, aside from the above study, there is little specific Information about CPR outcomes In dialysis patients. Thus, the risks and benefits of CPR are difficult for nephrologlsts to enumerate In discussions with their dialysis patients. We conducted this study to answer the following three questions about CPR in dialysis patients. (1) What percentage of dialysis patients undergo CPR, which factors distinguish those who do from those who do not, and how does this percentage compare with that of a control group of nondlalysis patients? (2) What are the causes of cardiopulmonary arrest preceding CPR in dialysis patients? (3) What are the outcomes of CPR in dialysis patients and how do they compare with those of nondialysis patients?
of
METHODS
for Health
Ethics
H5N, Morgantown,
1046-6673/0306-1238$03.00/0 Journal of the American 5ociety of Nephrology Copyright C 1992 by the American Society of Nephrology
1238
days
18. 1991. center
about
dialysis
death.
resuscitation is a procedure that in extended survival for dialysis patients.
In discussions
with
ventilation of
O
3:1238-1243)
resuscitation,
with
results
Key Words:
Penal-Electrolyte School
renal failure are believed to have a rate after cardiopulmonary resuscitais little specific information about the cardiopulmonary resuscitation in diTo be better able to inform dialysis assist them in decision making about
cardiopulmonary alysis
Secof
PA Soc.
(J. Am.
School
time
this information.
of Medicine, of
Medicine,
University
the
cardiopulmonary
Morgan-
WV
tion of Nephrology, West Virginia Medicine, Morgantown, WV
on mechanical at
and
Law,
West
WV 26506.
Study
Population
Dialysis Patients. tients of the West
All Virginia
adult chronic Health Care
Volume
3
‘
dialysis paCooperative
Number
6
‘
1992
Moss et al
who experienced a cardiopulmonary arrest between January 1983 and May 1991 were included. Patients were identified from the dialysis unit and West Virginla University Hospitals records of CPR procedures and patient deaths. All of these patients underwent CPR unless a “Do Not Resuscitate” order had been written, or unless they were found dead with rigor mortis. They were identified retrospectively far the years 1 983 to 1 986 and prospectively far 1 987 to 1991. The dialysis program of the West Virginia Health Care Cooperative provided dialysis of 1 00 patients on average per year during the study and was treating 1 30 patIents at the end of the study. Patients were dialyzed In one of two free-standing units. Dialysis care at each unit was provided by registered nurses who were certified in Advanced Cardiac Life Support by the American Heart Association. All inpatient care was provided at West Virginia University Hospitals. Control Patients. Control group patients were ineluded In this study If they were adults and met the following criteria: ( 1 ) experienced a cardiopulmonary arrest while an inpatient at West Virginia University Hospitals, (2) underwent CPR between March 1987 and May 1989, and (3) dId not have acute or chronic renal failure requiring dialysis. Control group patlents were Identified retrospectively from hospital records of consecutive CPR procedures between March 1987 and May 1989. Each patient chart was reviewed for the following patient parameters: age: gender; dialysis treatment (peritoneal, hemodlalysis, or none); survival after CPR; camorbid conditions including diabetes, chronic pulmonary disease, cardiac disease, malignancy, cerebrovascular disease, and sepsis; and cause of cardiopulmonary arrest. Charts were also reviewed for CPR parameters: performance of CPR, duration of procedure, location, and complications. The percentage of dialysis patients undergoing CPR was calculated by dividing the number of patients on wham CPR was performed by the number of dialysis patients experiencing cardiopulmonary arrest during the study period. The percentage of control group patients undergoing CPR was calculated by dividing the number of patients on whom CPR was performed by the number of hospital patients experiencing cardlopulmonary arrest during the study period. Patients who were dead on arrival In the emergency department, stillborn births, and patients dying in the operating room were not Included because CPR was not attempted In the first two groups and CPR procedure records were not submitted far the last group.
Follow-Up Survival to 6 months control group patients
Journal
of the
American
was
after CPR determined
Society
in
of Nephrology
dialysis and by reviewing
dialysis and hospital records and, when these were incomplete, by contacting the primary clan. For the purpose of this study, CPR was according to the Guidelines far Cardiopulmonary suscltatian and Emergency Cardiac Care American Heart Association (15).
Statistical
records physidefined Reof the
Analysis
Comparisons of population proportions were performed by the x2 test with Yates’ correction and the Fisher’s exact test where appropriate. Parametric data were analyzed by the t test for independent samples. P values of hess than 0.05 were considered significant. Data are presented as the mean ± standard deviation. This study protocol was approved by the West Virgmnla University Institutional Review Board far the Protection of Human Subjects.
RESULTS Patients
and
Rates
of CPR
Between 1 983 and 1 99 1 , 22 1 dialysIs patients experienced cardiopulmonary arrest, and 74 (34%) underwent CPR. The patients who underwent CPR were younger. and there was a trend for the patients to more often be men. A smaller percentage also had cancer (Table 1 ). The diabetics who underwent CPR were significantly younger than those who did not (56 ± 1 3 versus 62 ± 1 2 yr: P 0.007). The mean age of the men and women undergoing CPR was the same for bath diabetics and nondlabetics. There was no difference in the percentage of patients undergoing CPR on the basis of their dialysis modality: 49 (34%) of 143 hemodlalysls patients and 14 (31%) of 45 peritoneal dialysis patients. Eleven (31%) of 35 patients who had been on both In the recent past underwent CPR. Sixty-three (85%) patIents experlenced cardiopulmonary arrest In the hospital, six experienced It in their homes, and five experienced It In the outpatient dialysis units. From 1987 to 1989, 1,201 control group patients experienced cardiopulmonary arrest, and 247 (2 1 %)
TABLE I . Demographics of dialysis patients experiencing cardiopulmonary arrest PR
NoCPR (N=147)
(N=74)
Mean Age (yr) No. of Men (%) No. of Diabetics
(%)
No. of Diagnosis
of Cancer
(%)
Mean Time on Dialysis (months)
‘#{176}
58 ± 15
65 ± 12
0.001
41 (55)
63 (43)
0.08
39 (53) 8 (1 1)
81 (55) 43 (29)
NS 0.007
24
20 ± 26
±
26
NS
1239
CPR
in Dialysis
Patients
TABLE 2. Comparison
of dialysis
and
control
patients
undergoing
CPR
Dialysis (N= 74)
Mean Age (yr) No. of Men (%)
(%)
No. of Diabetics
Mean
Serum
Creatinine
(,mol/L)
58 ± 15 41 (55) 39 (53) 740 ± 290
underwent CPR. The percentage of control group patients who received CPR was less than that of dialysis patients (21 versus 33%; P 0.0002). These patients were alder, and fewer were diabetics campared with the dialysis patients undergoing CPR (Table 2). The diabetics in the control group were significantly older than the diabetic dialysis patients who underwent CPR (68 ± 1 1 versus 56 ± 13 yr; P < 0.00 1 ). There was no difference in the mean age of the control group compared with that of the entire dialysis patient population (63 ± 1 6 versus 62 ± 14 yr; P = not significant [NS]). The mean age of the men in the control group was significantly less than that of the women (61 ± 17 versus 67 ± 15 yr: P = 0.004). The percentage of patients with comorbid conditions-chronic pulmonary disease, cardiac disease, malignancy. cerebrovascular disease, neurologic disease, and sepsis-did not differ between dialysis patients undergoing CPR and control group patients.
Causes
of Cardiopulmonary
Arrest
The causes of cardiopulmonary arrest In the dlalysls patients are listed In Table 3. Fewer than 10% of the arrests (7 of 74) occurred while patients were receiving a hemodlalysis treatment, yielding a cardlapulmonary arrest rate on dialysis of roughly 1 per 82 patient yr. All of these arrests were likely precipitated in some way by the dialysis process: In six cases, It Is likely that the cardiovascular stress of hemodialysis contributed to the arrests. Five of these patients had known severe cardiac disease (four had lschemlc disease, and one who had a cardiomyapathy also had an allergic reaction to a dialyzer). and the sixth had amyloldosls and developed refractory hypotenslon. In the seventh patient, a dialysis-related air embolus caused the arrest. Two (3%) of the arrests were the result of hyperkalemia. One patient with atherosclerotic cardiovascular disease suffered a cardiac arrest from electromechanical dissociation after receiving phenytoin at a rate greater than 25 mg/ mm.
Resuscitation
Outcomes
The group
after CPR in the dialysis and Is listed In Table 4. There
1240
survival patients
and
Control (N=
Survival control was no
Group
247)
64 ± 16 147 (60)
0.004 NS
57 (23) 160 ± I 10
0.001
TABLE 3. Causes dialysis patients
0.001
of cardiopulmonary
arrest
in No. of Patients
Undetermined
Cardiac
27
Arrhythmia
Ventricular Fibrillation Cardiac Arrest During Dialysis Secondary to cardiac arrhythmia Secondary
to air emboli
Secondary
to hypotensionb
Secondary
to dialyzer
Myocardial Asystole
7
4
reactionc
Infarction
Electromechanical Sepsis
Respiratory Cardiac Cardiac
11 (1)#{176}
6 6 4(1)
Dissociation
3(1)
Arrest Secondary Arrest Arrest
to Aspiration
3 (2)d
Secondary Secondary
to Hemorrhage to Pulmonary
2 2
Secondary Secondary
to Hyperkalemia to Fat Emboli
2(1)
Edema Cardiac Cardiac Total 0
Arrest Arrest
74 (6)
Numbers
in parentheses
indicate
number
hypotension
in a patient
with
of patients
surviving
to
discharge. b
Refractory
C
Allergic
reaction
to a dialyzer
amyloidosis.
in a patient
with
a severe
cardiomy-
opathy. d
One
patient
in each
group
survived
6 months
after
CPR.
difference in initial successful resuscitation of dialysis and control group patients (27 [37%] of 74 versus 98 [40%] of 247; P = NS). The mean duration of CPR was significantly less In dialysis and control group patients who were successfully resuscitated than in those who were not (dialysis patients, 22 ± 1 7 versus 37 ± 1 8 mm; P 0.008; control group, 18 ± 19 versus 36 ± 21 mm; P < 0.001). There was no significant difference In the mean duration of resuscitation for successfully resuscitated dialysis and control group patients. After CPR, 6 (8%) of 74 (95% confIdence interval, 2 to 14%) dialysis patients, three men and three women, survived to hospital discharge compared with 30 (12%) of 247 (95% confIdence interval, 8 to 16%) control group patIents (P = NS). None of the
Volume
3
‘
Number
6
‘
1992
Moss et al
TABLE 4. Survival Patients
After
CPR in Dialysis
and
Control Group
Dialysis (N=
No. of Resuscitations (%) No. of Discharges (%) No. SurvivIng at Six Months
(%)
74)
Control
(N=
P
247)
27 (37)
98 (40)
NS
6 (8) 2 (3)
30 (12) 23 (9)
NS 0.044
Twenty-one (78%) of the 27 dialysIs patients who were successfully resuscitated did not live to discharge: 20 (95%) of 21 requIred Intubatlon and mechanlcal ventilation for a mean of 4.4 days before death. Only three of the successfully resuscitated patients who did not hive to discharge had autopsies. so data on other complications of CPR in these patients are unavailable.
DISCUSSION dialysis patients who were resuscitated at home or in the dialysis unit survived to discharge. At 6 months after CPR, 2 (3%) of 74 dIalysis patients were still alive compared with 23 (9%) of 247 controls (P = 0.044). The presence of diabetes did not affect survival to hospItal discharge after CPR In dialysis or control group patients. Three of 39 diabetic dialysis patients lived to dIscharge compared with 3 of 35 nondlabetic dialysis patients (8 versus 9%: P NS). Six of 51 diabetic control group patients lived to discharge compared with 24 of 1 76 nondiabetic control group patients (12 versus 14%: P = NS). Four of the six dialysis patients who survived to hospital discharge after CPR died within 4 months of the resuscitation. One patIent with end-stage heart disease who also had diabetes and a prior stroke discontinued dialysis and died within 3 months of her CPR. The second patient was a 30-yr-old type I diabetic who had had a previous myocardial infarction and who was found dead In bed 3 months and 1 day after resuscitation. The third patient, who also had end-stage heart disease, experienced a second cardIac arrest 3 months and 8 days after his first cardiac arrest and died 3 days later. The fourth patient, who had arrested after a phenytoin Infusion and who was hospitalized several months later for weight loss, was found dead In bed 4 months and 1 day after resuscitation. Two dialysis patients lived for more than 6 months after CPR. The first, who had experienced a respiratory arrest after aspiration, was debIlitated and remalned in the hospital for 2/2 months after CPR. He died 1 4 months after CPR from complications of a stroke. His baseline weight was 55 kg, and he weighed 36 kg shortly before his death. The second, who had a respiratory arrest as a complication of sepsis, remained on mechanical ventilation for 23 days and was discharged to a nursing home 3#{189} months later. She has survived 1 9 months, has required oxygen by nasal cannula 24 h/day for her severe chronic obstructive pulmonary disease, and has been confined to a wheelchair. She continues to live in a nursing home, and although she Is happy to be alive, she has requested not to be resuscitated again.
Journal
of the American
Society
of Nephrology
ThIs study had several noteworthy findings. First, the percentage of dialysis patients undergoing CPR was more than that of the control group. It Is possible that the previously described Inclination of nephrohogists to use CPR more than other Internists, both in dialysis patients and In other patients with Impaired functional status, may account for this fInding (16). Second, the dialysis patients who underwent CPR were significantly younger than those who did not. Because, in our study, the patients who did not have CPR had requested not to be resuscitated, thIs fInding is consistent with reported preferences of older dlahysls patients to decline CPR more often than younger ones (13,17). Third, despite the fact that the dialysis patients were signIficantly younger than the control group patients, there was a lower long-term survIval In the dialysis patients. Overall, fewer than 10% of the dialysis patients survived to hospital discharge and only 3% were stIll alive 6 months after CPR. Although many more of the dIalysis patients were diabetics, diabetes did not account for the worse survival rate in dialysis patients. Other comorbid conditions also did not account for this difference. It would appear that the underlying ESRD Is responsible for the poor survival after CPR in dialysIs patients. Even those six dialysIs patients who did survive to hospItal dIscharge had limited hong-term benefIt from the CPR. Two thirds were dead within 4 months, and two of these had a progressively downhIll course, one dying after the discontinuation of dialysIs. Both patients who survived longer than 6 months sustained a marked decrease In their functional status compared wIth prearrest status. These findIngs are similar to those for nondlalysis patIents who were manitored for 6 months after resuscItatIon (18). Fourth, the dialysis patients who were successfully resuscitated experienced sIgnifIcant short-term marbldlty and mortality. Over three quarters of them died on average within a week. Of these. 95% were Intubated and on mechanical ventilatIon in an Intensive care unit at the time of death. SIx lImitations of this study need to be acknowledged. The outcomes In fewer than 100 dialysis patients undergoing CPR are reported. It is possIble that with large numbers a signifIcant decrease in survival
I241
CPI?
in Dialysis
Patients
to hospital discharge might be seen in dialysis patients compared with others. However, this study reports 8 yr of observation of CPR outcomes and, in the last 4 yr. there has been no trend toward a statistically significant difference. The hack of difference in either duration of resuscitation or percentage of patients successfully resuscitated supports the observation that the short-term results of CPR in dIalysis and control patients do not vary. Yet, despite the small numbers, this study shows clearly that dialysis patients undergoing CPR have a significantly worse 6-month survival compared with that of nondialysis patIents. A second limitation is that the outcomes of 247 patients In the control group who all had CPR in the hospital are compared with those of 74 dialysis patlents, 1 1 of wham had CPR in their homes or the dialysIs unit. Despite this dissimilarity in location, the percentage of patients successfully resuscitated and surviving to discharge did not differ between the two groups. Third, It could be argued that the how survival rates for dialysis and control group patients are the result of poor CPR technique at West Virginia University Hospitals. However, the survival to discharge and 6month survival of our control group patients are comparable to those previously reported (18). Fourth, in this study, the outcomes of CPR in dialysls patients aver an 8-yr period, from 1 983 to 1 99 1 , are compared with those far control patients over a more recent part of this period. from 1987 to 1 989. It would be desirable if the dialysis patients and control patients undergoing CPR were compared over the same period of time, but West Virginia University Hospitals’ system for tracking all resuscitations was Implemented in 1 987 and a retrospective analysis of CPR far the years before 1 987 would not be accurate. Ta examine this limitation, the age, gender. and percentage of dialysis patients undergoIng CPR after 1 986 were compared with those of dIalysis patients undergoing CPR in the earlier years of the study. There were no differences in age, gender, or rate of CPR, and the percentage of patients surviving to discharge were similar: 9% for the years 1983 to 1986 and 7% for the years 1987 to 1991. The 6-month survival far bath groups was very law: none of the 33 patients In the earlier years survived, and 2 (5%) of 41 patIents in the later years survived. Fifth, although it was possible to verify the dialysis unit records of deaths and CPR with hospital records, It Is likely that same control patients undergoing CPR during the study period were missed because hospital CPR documentation forms were not submitted. Sixth, multiple statistical comparisons were made in thIs study and same of the results may have arisen by chance alone. Despite the paucity of information about CPR out-
I242
comes in dialysis patients and the inference from the experience of CPR in renal failure patients that the expected outcomes would be poor, mast dialysis patients indicate that they want CPR in the event of cardiopulmonary arrest (13,14,17,19). Our data show that CPR is a procedure that rarely results in extended survival far dialysis patients. Kjehlstrand has written that nephrolagists need to be more open with their patients and more realistic about what they can and cannot do (20). Such discussians need to contain useful information far patients that allows them to make informed decisions, and nephralogists have been encouraged to obtain advance directives from patients as part of these discussions (2 1 ,22). The poor outcomes of CPR in dialysis patients and the automatic presumption that CPR will be performed unless a “Do Nat Resuscitate” order has been written should be included in the information that nephrolagists provide during canversatians about CPR with their dialysis patients. In this way, nephrahagists can assist patients in making informed decisions about their future treatment.
ACKNOWLEDGMENTS The authors L. Burkhard,
thank Mary Hoizer, Sue Ann Crowder
Virginia
Health
Records
Department
sistance
in data
statistical
expressed represent
Cooperative, of
Foundation
are
Virginia Paul
Cynthia
and two is supported
and
West
collection;
analysis;
preparation; A. H. Moss Family
Care
RN.. Upton,
and
of
necessarily
those
Conrad
for
reviewers by a grant
the
Pew
the
authors of the
Pesyna
University Hshieh,
F. Jamison
anonymous in part
those
B.
Jennifer Domico, M.D. , the nurses
Charitable
and supporting
RN.. of the
,
for
assistance
West
Medical
Hospitals
Ph.D.
John
of the for
as-
assistance
in
in manuscript
for helpful comments. from the Henry J. Kaiser Trusts.
should
The
not
be
opinions
taken
to
groups.
REFERENCES 1 . McGrath citation-after Emerg
2. 3.
4. 5.
7. 8.
In-house cardiopulmonary a quarter of a century.
resusAnn
1987:16:1365-1368.
Applebaum GE, King JE, Finucane TE: The outcome of CPR initiated in nursing homes. J Am GeriatrSac 1990:38:197-200. Murphy DJ, Murray AM, Robinson BE, Campion EW: Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989; 111:199-205. Faber-Langendoen K: Resuscitation of patients with metastatic cancer: Is transient benefit still futile? Arch Intern Med 1 99 1 ; 151:235-239. Blackhall U: Must we always use CPR? N Engl J Med
6.
Med
RB:
1987:317:1281-1285.
Moss AH: Informing the patient about cardiopulmonary resuscitation: When the risks outweigh the benefits. J Gen Intern Med 1989:4: 346-355. Saphir R: External cardiac massage: Prospective analysis of 123 cases and review of the hiterature. Medicine (Baltimore) 1968:47:73-87. Hollingsworth JH: The results of cardiapulmanary resuscitation: A 3-year university hospital experience. Ann Intern Med 1969:71:459-466.
Volume
3
.
Number
6
‘
1992
Moss et al
Kyff J, Pun VK, Raheja R, Ireland T: Cardlopulmonary resuscitatIon In hospitalized patients: Continuing problems of decision-making. Crit Care Med 1987;15:41-43. 1 0. Scott RPF: CardIopulmonary resuscitatIon in a teaching hospital. Anaesthesia 1981:36: 526-530. 1 1 . Klassen GA, Broadhurst C, Peretz DI, Johnson AL: Cardiac resuscitation In 1 26 medIcal patlents using external cardiac massage. Lancet l963;l:1290-1292. 1 2. Johnson AL, Tanser PH, Ulan RA, Wood TE: Results of cardiac resuscitation in 522 patients. Am J Cardlol 1967:20:832-835. 1 3. Tzamaloukas AH, Zager PG, Quintana BJ, Nevarez M, Rogers K, Murata GH: Mechanical cardiopulmonary resuscitation choice of patients on chronic peritoneal dialysis. Peritoneal Dial Int 1990:10:299-302. 14. Holley JL, Finucane TE, Moss AH: Dialysis patients’ attitudes about cardiopulmonary resuscitatIon and stopping dialysis. Am J Nephrol 1 989;9:245-25 1. 1 5. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac 9.
Journal
of the
American
Society
of Nephrology
care (ECC). JAMA 1986:255:2905-2989. Foulks CJ, Holley JL, Moss AH: The use of cardiopulmonary resuscitation: how nephralogists and Internists dIffer. Am J Kidney Dis 1991:18:379-383. 1 7. Quintana BJ, Nevarez M, Rogers K, Murata GH, Tzamaloukas AH: Reaction of patients on chronic dialysis to dIscussions about cardlopulmonary resuscitation. ANNA J 1991:18:29-32. 1 8. Bedell SE, Delbanco TL, Cook EF, Epstein FH: Survival after cardiopulmonary resuscitation In the hospital. N Engl J Med 1983;309:569-576. 1 9. Rogers K, Crawford DR. Tzamaloukas AH: Cardiopulmonary resuscitation preferences of patients on chronic hemodlalysis. Dial Transplant 1990: 19: 182-184. 20. Kjellstrand CM: Who should decide about your death? JAMA 1992:267:103-104. 2 1 . Singer PA: Nephrohogists’ experience with and attitudes towards decisions to forego dialysis. J Am Soc Nephrol 1992:2:1235-1240. 22. Sehgal AS, Galbraith A, Chesney M, Schoenfeld P, Charles G, Lo B: How strictly do dialysis patients want their advance directives followed? JAMA 1992:267:59-63. 16.
I 243
