It is unfortunate, but some of us will approach a time when we know that the advanced prostate cancer we have been battling has gotten the better of us and will end our life in the near future. If we are admitted into the hospital we will be asked to sign a lot of papers that entails making a lot of decisions about our future medical care. Even if we are not going to be admitted to the hospital these decisions will need to be made and expressed to our families and medical caregivers. Among these many decisions will be the directive letting our caregivers know if we want to have cardiopulmonary resuscitation (CPR) if our heart stops functioning.

In order to be really competent to make the right decisions we need to discuss the issues with our families and our doctors. We need to really understand what the procedures are, how they are performed and what the possible results of the procedures could be on the remaining time we might have left. More importantly, we need to know that CP{R will not cure our cancer, if anything it will probably leave us in a weaker and more compromised state.

Usually, when we discuss the decision whether to allow CPR to be performed (or to direct that no CPR be used on us) we have a conversation about it. But most of us do not really know what is done, how it is performed and what are the possible results of the procedure. In essence we make this life and death decision without complete knowledge.

In a very unusual situation this issue was examined. In a study that will appear in the Journal of Clinical Oncology patients with terminal cancer (not necessarily prostate cancer) viewed a three-minute video demonstrating cardiopulmonary resuscitation (CPR). The findings of the study were that after viewing the video more people were less likely to indicate a preference for receiving CPR in the event of an in-hospital cardiac arrest than were patients who only listened to a verbal description of the procedure.

Angelo Volandes, MD, MPH, of the Massachusetts General Hospital (MGH) Department of Medicine, a corresponding author of this report said, “It really is incumbent on us, as physicians, to help our patients understand their options at the end of life. ….. Our results clearly show that educational videos can help supplement – not supplant – the patient/doctor relationship by reinforcing, not replacing, the conversations that must take place between doctors and patients.”

In this investigation – called the Video Images of Disease for Ethical Outcomes (VIDEO) study – patients from the Boston Medical Center, Queens Hospital Cancer Center in New York, and Vanderbilt-Ingram Cancer Center in Nashville were included. One third of those in the study were African American and 10 percent Hispanic. This study focused on the choice to receive CPR, a decision, Volandes explains, that can have a major impact on the course of a patient’s care.

All of the cancer patients in the study were aware that their prognosis was less than one year. They were invited to participate in the study immediately after a scheduled clinic visit. Those agreeing to participate first completed a questionnaire including details of their personal background and their current preferences regarding CPR. They then were randomized into two groups, completed assessments of their current knowledge about CPR and general health information, and listened to identical verbal narratives describing the goals, processes and risks of CPR – including the likelihood of successful resuscitation in patients with advanced cancer.

The investigational group was then shown the video which included images of a simulated CPR procedure conducted on a mannequin and of a real patient on mechanical ventilation receiving intravenous medication. Then both groups completed a second questionnaire that once again ascertained their knowledge about CPR and asked the same questions regarding their personal CPR preferences. Six to eight weeks later they were asked to take a follow-up questionnaire.

The research project included 150 patients. From this group 70 viewed the video, while 80 did not view the video. Before beginning the study about half of those in both groups indicated they would choose to receive CPR. That preference dropped slightly – from 54 to 48 percent – among those who only listened to the verbal description of CPR, but among those who also viewed the video, the preference for CPR dropped by more than half – from 49 percent to 20 percent.

The follow-up questionnaire was administered to 67 of the participants – 30 who had viewed the video and 37 who had not. More than half of those in each group had died before they were asked to take the follow-up questionnaire. Among patients who were contacted, 17 percent of those who saw the video said they would choose to receive CPR, as did 41 percent of the controls. Among those who viewed the video, 90 percent indicated that it was helpful, 93 percent that they were comfortable viewing it, and 98 percent said they would probably or definitely recommend viewing the video to other patients with advanced cancer.

“We now have even more evidence that videos are more informative and, in combination with verbal discussion, give patients more knowledge with which to make these important decisions,” says Volandes. “When patients have more knowledge, they tend not to want more aggressive interventions, and this effect persists over time. Not only were patients overwhelmingly comfortable viewing the videos, but those patients who had lower levels of health literacy were particularly likely to indicate that the video was helpful to them. We need to provide all patients with the tools to understand their treatment options, especially for end-of-life care.”

Joel T. Nowak, M.A., M.S.W.