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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024; 37:805-817. [PMID: 38609749 DOI: 10.1016/j.aucc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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2
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Plaisance A, Mallmes J, Kamateros A, Heyland DK. Evaluation of a French adaptation of a community-based advance serious illness planning decision aid. PEC INNOVATION 2023; 3:100182. [PMID: 38213761 PMCID: PMC10782113 DOI: 10.1016/j.pecinn.2023.100182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/17/2023] [Accepted: 06/17/2023] [Indexed: 01/13/2024]
Abstract
Objective The Plan Well Guide™ (PWG) is a decision aid that empowers lay persons to better understand different types of care and prepares them, and their substitute decision-makers, to express both their authentic values and informed treatment preferences in anticipation of serious illness. We aimed to determine the acceptability of the newly translated French PWG and to evaluate decisional readiness and decisional conflict following its use by lay people. Methods This is an acceptability and exploratory outcomes evaluation.Participants were requested to read and complete the French PWG and to engage in an online interview. We used the Acceptability Scale to determine the acceptability and the Preparation for Decision-making Scale and decisional conflict Scale to evaluate decisional readiness. Results Forty-two (42) people participated. The average score on the Acceptability Scale was 18.1 (scale range: 4-20 [high-better]) and 26.6 on the Preparation for Decision-Making Scale (scale range: 6-30 [high-better]). A significant number of respondents reported needing more support to help them make better decisions. Conclusion The French PWG has been deemed acceptable and relevant for lay people not currently facing clinical decisions. Innovation The Plan Well Guide is innovative as it is the first decision aid empowering lay people for advance serious illness planning.
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3
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Chan PS, Greif R, Anderson T, Atiq H, Bittencourt Couto T, Considine J, De Caen AR, Djärv T, Doll A, Douma MJ, Edelson DP, Xu F, Finn JC, Firestone G, Girotra S, Lauridsen KG, Kah-Lai Leong C, Lim SH, Morley PT, Morrison LJ, Moskowitz A, Mullasari Sankardas A, Mustafa Mohamed MT, Myburgh MC, Nadkarni VM, Neumar RW, Nolan JP, Odakha JA, Olasveengen TM, Orosz J, Perkins GD, Previdi JK, Vaillancourt C, Montgomery WH, Sasson C, Nallamothu BK. Ten Steps Toward Improving In-Hospital Cardiac Arrest Quality of Care and Outcomes. Resuscitation 2023; 193:109996. [PMID: 37942937 PMCID: PMC10769812 DOI: 10.1016/j.resuscitation.2023.109996] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Affiliation(s)
- Paul S Chan
- Mid-America Heart Institute, Kansas City, MO, United States.
| | - Robert Greif
- Department of Anesthesiology and Pain Medicine, University of Bern, Switzerland
| | - Theresa Anderson
- Department of Internal Medicine, University of Michigan Medical, Ann Arbor, United States
| | - Huba Atiq
- Centre of Excellence for Trauma and Emergencies, Aga Khan University Hospital, Pakistan
| | | | | | - Allan R De Caen
- Division of Pediatric Critical Care, Stollery Children's Hospital, Edmonton, Canada
| | - Therese Djärv
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Ann Doll
- Global Resuscitation Alliance, Seattle, WA, United States
| | - Matthew J Douma
- Department of Critical Care Medicine, University of Alberta, Canada
| | - Dana P Edelson
- Department of Medicine, University of Chicago Medicine, IL, United States
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, China
| | - Judith C Finn
- School of Nursing, Curtin University, Perth, Australia
| | - Grace Firestone
- Department of Family Medicine, University of California Los Angeles Health, Santa Monica, United States
| | - Saket Girotra
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, United States
| | | | | | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Peter T Morley
- Department of Intensive Care, The University of Melbourne, Australia
| | - Laurie J Morrison
- Division of Emergency Medicine, University of Toronto, Ontario, Canada
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, The Bronx, NY, United States
| | | | | | | | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care, Childrens Hospital of Philadelphia, PA, United States
| | - Robert W Neumar
- Department of Emergency Medicine, University of Michigan, Ann Arbor, United States
| | | | | | - Theresa M Olasveengen
- Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Judit Orosz
- Department of Medicine, The Alfred, Melbourne, Australia
| | | | | | | | | | | | - Brahmajee K Nallamothu
- Department of Internal Medicine, University of Michigan Medical, Ann Arbor, United States
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4
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Nallamothu BK, Greif R, Anderson T, Atiq H, Couto TB, Considine J, De Caen AR, Djärv T, Doll A, Douma MJ, Edelson DP, Xu F, Finn JC, Firestone G, Girotra S, Lauridsen KG, Leong CKL, Lim SH, Morley PT, Morrison LJ, Moskowitz A, Mullasari Sankardas A, Mohamed MTM, Myburgh MC, Nadkarni VM, Neumar RW, Nolan JP, Athieno Odakha J, Olasveengen TM, Orosz J, Perkins GD, Previdi JK, Vaillancourt C, Montgomery WH, Sasson C, Chan PS. Ten Steps Toward Improving In-Hospital Cardiac Arrest Quality of Care and Outcomes. Circ Cardiovasc Qual Outcomes 2023; 16:e010491. [PMID: 37947100 PMCID: PMC10659256 DOI: 10.1161/circoutcomes.123.010491] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Affiliation(s)
| | - Robert Greif
- Department of Anesthesiology and Pain Medicine, University of Bern, Switzerland (R.G.)
| | - Theresa Anderson
- Department of Internal Medicine, University of Michigan Medical, Ann Arbor (B.K.N., T.A.)
| | - Huba Atiq
- Centre of Excellence for Trauma and Emergencies, Aga Khan University Hospital, Pakistan (H.A.)
| | | | | | - Allan R. De Caen
- Division of Pediatric Critical Care, Stollery Children’s Hospital, Edmonton, Canada (A.R.D.C.)
| | - Therese Djärv
- Department of Medicine, Karolinska Institute, Stockholm, Sweden (T.D.)
| | - Ann Doll
- Global Resuscitation Alliance, Seattle, WA (A.D.)
| | - Matthew J. Douma
- Department of Critical Care Medicine, University of Alberta, Canada (M.J.D.)
| | - Dana P. Edelson
- Department of Medicine, University of Chicago Medicine, IL (D.P.E.)
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, China (F.X.)
| | - Judith C. Finn
- School of Nursing, Curtin University, Perth, Australia (J.F.)
| | - Grace Firestone
- Department of Family Medicine, University of California Los Angeles Health, Santa Monica (G.F.)
| | - Saket Girotra
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas (S.G.)
| | | | - Carrie Kah-Lai Leong
- Department of Emergency Medicine, Singapore General Hospital (C.K.-L.L., S.H.L.)
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital (C.K.-L.L., S.H.L.)
| | - Peter T. Morley
- Department of Intensive Care, The University of Melbourne, Australia (P.T.M.)
| | - Laurie J. Morrison
- Division of Emergency Medicine, University of Toronto, Ontario, Canada (L.J.M.)
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, The Bronx, NY (A.M.)
| | | | | | | | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care, Childrens Hospital of Philadelphia, PA (V.N.)
| | - Robert W. Neumar
- Department of Emergency Medicine, University of Michigan, Ann Arbor (R.W.N.)
| | - Jerry P. Nolan
- University of Warwick, Coventry, United Kingdom (J.P.N., G.D.P.)
| | | | - Theresa M. Olasveengen
- Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway (T.M.O.)
| | - Judit Orosz
- Department of Medicine, The Alfred, Melbourne, Australia (J.O.)
| | - Gavin D. Perkins
- University of Warwick, Coventry, United Kingdom (J.P.N., G.D.P.)
| | | | | | | | | | - Paul S. Chan
- Mid-America Heart Institute, Kansas City, MO (P.S.C.)
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Muacevic A, Adler JR, Turcotte S, Laflamme B, Heyland DK, Leblanc A. A Quality Assessment of Goals of Care Forms in a Sample of Older Patients in Various Care Settings in Quebec, Canada. Cureus 2023; 15:e33872. [PMID: 36819330 PMCID: PMC9933571 DOI: 10.7759/cureus.33872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE The objective of this study is to assess the completion and content of the Goals of Care (GOC) forms in three care settings in the province of Quebec, Canada. METHODS This is a retrospective, cross-sectional, mixed methods analysis of data extracted from the charts and GOC forms of patients aged over 65 who received services during the year 2018 in one of the three following care settings: (i) long-term care facility, (ii) acute care hospital, and (iii) home support services of a regional healthcare and social services center. The completion of the GOC form includes six essential sections. If one or more of the sections were not fulfilled, we considered the form incomplete. We used descriptive analysis to look at the information in the six sections and a thematic analysis to assess the information in an open-ended section. RESULTS We audited 589 charts, of which 67% contained a GOC form and only 96 (16%) a completed one. The most popular goal of care was ensuring comfort as a priority over prolonging life, selected on 40% of the forms. The majority of the included patients (89%) did not want cardiopulmonary resuscitation (CPR) to be attempted in the case of cardiac arrest. There was no indication of the use of advance medical directives, and scarce indication of the use of former GOC forms (18%) and living wills (2%) in completing the forms. Comments were included in 65% of the open-ended sections. The most frequent themes related to the use or non-use of interventions and to potential transfers to the hospital or to an intensive care unit. We found that the open-ended section was used on 24 forms to specify a different goal of care applicable in the event of further health deterioration. DISCUSSION AND CONCLUSIONS A significant proportion of charts (84%) did not contain a completed GOC form; key aspects of advance care planning were rarely considered in establishing the patient's goal of care, and the form itself lacked utility given the frequency and nature of qualitative comments. As a final product of serious illness communication and decision-making, our findings suggest that there are significant quality issues, that patients are at risk of intensification of care at the end of life, and that more needs to be done to improve serious illness decision-making and documentation.
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Qureshi SP, Jones D, Dewar A. Physicians' Conceptions of the Dying Patient: Scoping Review and Qualitative Content Analysis of the United Kingdom Medical Literature. QUALITATIVE HEALTH RESEARCH 2022; 32:1881-1896. [PMID: 35981561 PMCID: PMC9511242 DOI: 10.1177/10497323221119939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Most people in high income countries experience dying while receiving healthcare, yet dying has no clear beginning, and contexts influence how dying is conceptualised. This study investigates how UK physicians conceptualise the dying patient. We employed Scoping Study Methodology to obtain medical literature from 2006-2021, and Qualitative Content Analysis to analyse stated and implied meanings of language used, informed by social-materialism. Our findings indicate physicians do not conceive a dichotomous distinction between dying and not dying, but construct conceptions of the dying patient in subjective ways linked to their practice. We argue that the focus of future research should be on exploring practice-based challenges in the workplace to understanding patient dying. Furthermore, pre-Covid-19 literature related dying to chronic illness, but analysis of literature published since the pandemic generated conceptions of dying from acute illness. Researchers should note the ongoing effects of Covid-19 on societal and medical awareness of dying.
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Affiliation(s)
- Shaun Peter Qureshi
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Derek Jones
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Avril Dewar
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
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7
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Shalak M, Shariff MA. Together Till the End: Two Cases of Withdrawal of Life Support. Cureus 2022; 14:e27852. [PMID: 36134113 PMCID: PMC9481216 DOI: 10.7759/cureus.27852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 11/28/2022] Open
Abstract
It’s important to consider patients’ wishes regarding treatment options, especially near the end of life to allow patients to die with dignity. Worldwide variability exists regarding the palliative extubation decision, which is performed to relieve suffering by the termination of mechanical ventilation and withdrawal of the breathing tube, consequently avoiding the prolongation of death. It is only performed when it is consistent with patients' values and prognosis. This variability is even more prominent in low-income and developing countries. We are presenting a case report of two patients, a husband and a wife, who underwent palliative extubation and withdrawal of life support on the same day.
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8
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Jung H, Ko RE, Ko MG, Jeon K. Trends of in-hospital cardiac arrests in a single tertiary hospital with a mature rapid response system. PLoS One 2022; 17:e0262541. [PMID: 35025978 PMCID: PMC8757966 DOI: 10.1371/journal.pone.0262541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Most studies on rapid response system (RRS) have simply focused on its role and effectiveness in reducing in-hospital cardiac arrests (IHCAs) or hospital mortality, regardless of the predictability of IHCA. This study aimed to identify the characteristics of IHCAs including predictability of the IHCAs as our RRS matures for 10 years, to determine the best measure for RRS evaluation. Methods Data on all consecutive adult patients who experienced IHCA and received cardiopulmonary resuscitation in general wards between January 2010 and December 2019 were reviewed. IHCAs were classified into three groups: preventable IHCA (P-IHCA), non-preventable IHCA (NP-IHCA), and inevitable IHCA (I-IHCA). The annual changes of three groups of IHCAs were analyzed with Poisson regression models. Results Of a total of 800 IHCA patients, 149 (18.6%) had P-IHCA, 465 (58.1%) had NP-IHCA, and 186 (23.2%) had I-IHCA. The number of the RRS activations increased significantly from 1,164 in 2010 to 1,560 in 2019 (P = 0.009), and in-hospital mortality rate was significantly decreased from 9.20/1,000 patients in 2010 to 7.23/1000 patients in 2019 (P = 0.009). The trend for the overall IHCA rate was stable, from 0.77/1,000 patients in 2010 to 1.06/1,000 patients in 2019 (P = 0.929). However, while the incidence of NP-IHCA (P = 0.927) and I-IHCA (P = 0.421) was relatively unchanged over time, the incidence of P-IHCA decreased from 0.19/1,000 patients in 2010 to 0.12/1,000 patients in 2019 (P = 0.025). Conclusions The incidence of P-IHCA could be a quality metric to measure the clinical outcomes of RRS implementation and maturation than overall IHCAs.
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Affiliation(s)
- Hohyung Jung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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9
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Crosbie D, Ghosh A, Van Ekeren N, Dowling M, Hayes B, Cross A, Jones D. Non-beneficial resuscitation during in-hospital cardiac arrests in a metropolitan teaching hospital. Intern Med J 2021; 53:798-802. [PMID: 34865292 DOI: 10.1111/imj.15638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/28/2021] [Accepted: 11/28/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the prevalence of non-beneficial resuscitation attempts in hospitalised patients and identify interventions that could be used to reduce these events. METHODS A retrospective analysis was conducted of all adult IHCAs receiving cardiopulmonary resuscitation (CPR) in a teaching hospital over nine years. Demographics and arrest characteristics were obtained from a prospectively collected database. Non-beneficial CPR was defined as CPR being administered to patients who had a current not for resuscitation (NFR) order in place or who had an NFR order enacted on a previous hospital admission. Further antecedent factors and resuscitation characteristics were collected for these patients. RESULTS There were 257 IHCAs, of which 115 (44.7%) occurred on general wards, with 19.8% of all patients surviving to discharge home. There were 39 (15.2%) instances of non-beneficial CPR of which 28/39 (72%) occurred in unmonitored patients on the ward comprising nearly a quarter (28/115) of all arrests in this patient group. A specialist had reviewed 30/39 (76.9%) of these patients, and 33.3% (13/39) had a medical emergency team (MET) review prior to their arrest. CONCLUSIONS Over one in seven resuscitation attempts were non-beneficial. MET reviews and specialist ward rounds provide opportunities to improve the documentation and visibility of NFR status. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- David Crosbie
- Intensive Care Unit, Northern Health Epping, Melbourne, VIC, Australia
| | - Angaj Ghosh
- Intensive Care Unit, Northern Health Epping, Melbourne, VIC, Australia
| | | | - Monica Dowling
- Intensive Care Unit, Northern Health Epping, Melbourne, VIC, Australia
| | - Barbara Hayes
- Palliative Care Unit, Northern Health Epping, Melbourne, VIC, Australia.,Northern Clinical School, University of Melbourne, Melbourne, VIC, Australia
| | - Anthony Cross
- Intensive Care Unit, Northern Health Epping, Melbourne, VIC, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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11
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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12
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Dignam C, Brown M, Thompson CH. Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients. Gerontol Geriatr Med 2021; 7:23337214211003431. [PMID: 33796631 PMCID: PMC7983414 DOI: 10.1177/23337214211003431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely. This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.
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Affiliation(s)
- Colette Dignam
- University of Adelaide, SA, Australia.,Royal Adelaide Hospital, SA, Australia
| | | | - Campbell H Thompson
- University of Adelaide, SA, Australia.,Royal Adelaide Hospital, SA, Australia
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Kelly PA, Baker KA, Hodges KM, Vuong EY, Lee JC, Lockwood SW. Original Research: Nurses' Perspectives on Caring for Patients with Do-Not-Resuscitate Orders. Am J Nurs 2021; 121:26-36. [PMID: 33350694 DOI: 10.1097/01.naj.0000731652.86224.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Confusion about what a do-not-resuscitate (DNR) order means, including its misinterpretation as "do not treat," has been extensively documented in the literature. Yet there is a paucity of research concerning nurses' perspectives on DNR orders. PURPOSE AND DESIGN This mixed-methods study was designed to explore nurses' perspectives on the meaning and interpretation of DNR orders in relation to caring for hospitalized adults with such orders. METHODS Direct care nurses on three units in a large urban hospital were asked to respond online to a case study by indicating how they would prioritize care based on the patient's DNR designation. These nurses were then invited to participate in open-ended interviews with a nurse researcher. Interviews were audiotaped, transcribed, and analyzed. FINDINGS A total of 35 nurses responded to the case study survey. The majority chose to prioritize palliative care, despite no indication that any plan of care was in place. Thirteen nurses also completed a one-on-one interview. Analysis of interview data revealed this overarching theme: varying interpretations of DNR orders among nurses were common, resulting in unintended consequences. Participants also reported perceived variances among health care team members, patients, and family members. Such misinterpretations resulted in shifts in care, varying responses to deteriorating status, tension, and differences in role expectations for health care team members. CONCLUSIONS Nurses have opportunities to address misconceptions about care for patients with DNR orders through practice, education, advocacy and policy, and research.
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Affiliation(s)
- Patricia A Kelly
- Patricia A. Kelly is a research and evidence-based practice translationist at Texas Health Presbyterian Hospital Dallas, where Karen M. Hodges is a direct care nurse and Joyce C. Lee is a nurse manager. Kathy A. Baker is an associate professor and director of nursing research and scholarship at Texas Christian University Harris College of Nursing and Health Sciences, Fort Worth, where Suzy W. Lockwood is a professor and associate dean of nursing and nurse anesthesia. Ellen Y. Vuong is a clinical educator at Texas Health Resources University, Arlington. Funding for transcription services was provided by the Texas Health Resources Foundation. Contact author: Patricia A. Kelly, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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Wen FH, Chen CH, Chou WC, Chen JS, Chang WC, Hsieh CH, Tang ST. Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness. J Natl Compr Canc Netw 2020; 18:1658-1666. [PMID: 33285517 DOI: 10.6004/jnccn.2020.7601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/29/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders. PATIENTS AND METHODS Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling. RESULTS At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036-4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989-89.786; P=.008). Both arms issued DNR orders close to death (median, 5-6 days before death). CONCLUSIONS Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846.
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Affiliation(s)
- Fur-Hsing Wen
- 1Department of International Business, Soochow University, and
| | - Chen Hsiu Chen
- 2School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC
| | - Wen-Chi Chou
- 3Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.,4Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Jen-Shi Chen
- 3Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.,4Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Wen-Cheng Chang
- 3Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.,4Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Chia-Hsun Hsieh
- 3Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.,4Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Siew Tzuh Tang
- 3Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.,5Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC; and.,6Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung City, Taiwan, ROC
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Myall M, May C, Richardson A, Bogle S, Campling N, Dace S, Lund S. Creating pre-conditions for change in clinical practice: the influence of interactions between multiple contexts and human agency. J Health Organ Manag 2020; ahead-of-print. [PMID: 33103399 PMCID: PMC9251639 DOI: 10.1108/jhom-06-2020-0240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to explore what happens when changes to clinical practice are proposed and introduced in healthcare organisations. The authors use the implementation of Treatment Escalation Plans to explore the dynamics shaping the translational journey of a complex intervention from research into the everyday context of real-world healthcare settings.Design/methodology/approachA qualitative instrumental collective case study design was used. Data were gathered using qualitative interviews (n = 36) and observations (n = 46) in three English acute hospital trusts. Normalisation process theory provided the theoretical lens and informed data collection and analysis.FindingsWhile each organisation faced the same translational problem, there was variation between settings regarding adoption and implementation. Successful change was dependent on participants' ability to manage and shape contexts and the work this involved was reliant on individual capacity to create a new, receptive context for change. Managing contexts to facilitate the move from research into clinical practice was a complex interactive and iterative process.Practical implicationsThe paper advocates a move away from contextual factors influencing change and adoption, to contextual patterns and processes that accommodate different elements of whole systems and the work required to manage and shape them.Originality/valueThe paper addresses important and timely issues of change in healthcare, particularly for new regulatory and service-oriented processes and practices. Insights and explanations of variations in implementation are revealed which could contribute to conceptual generalisation of context and implementation.
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Affiliation(s)
- Michelle Myall
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Carl May
- Faculty of Public Health and Policy,
London School of Hygiene and Tropical Medicine
, London,
UK
| | - Alison Richardson
- School of Health Sciences,
University of Southampton
, Southampton,
UK
- Clinical Academic Facility, Southampton General Hospital,
University Hospital Southampton NHS Foundation Trust
, Southampton,
UK
| | - Sarah Bogle
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Natasha Campling
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Sally Dace
- School of Health Sciences,
University of Southampton
, Southampton,
UK
| | - Susi Lund
- School of Health Sciences,
University of Southampton
, Southampton,
UK
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Myers AL, Matthias MS. Nursing facility residents' cardiopulmonary resuscitation decisions. Int J Older People Nurs 2020; 15:e12344. [PMID: 32822117 DOI: 10.1111/opn.12344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/30/2020] [Accepted: 07/29/2020] [Indexed: 12/01/2022]
Abstract
CONTEXT As many as one-quarter of all residents in nursing facilities have cardiopulmonary resuscitation (CPR) as a documented choice in the medical record, despite the likelihood of limited medical benefit in this setting. OBJECTIVES The aim of this study was to understand the perspectives of healthcare providers and nursing facility residents regarding CPR decisions. METHODS We used qualitative interviews to examine the perspectives of residents with a documented decision for CPR in the medical record. We then compared residents' views with those of healthcare providers who routinely conduct advance care planning (ACP) conversations in the nursing facility setting. RESULTS Five themes emerged from the interviews: (a) Resident versus Provider Concerns, (b) Offering Information versus Avoidance, (c) Lack of Understanding of CPR, (d) Lack of Awareness, and (e) 'Don't Keep Me on Machines'. Residents held misconceptions about CPR and/or exhibited an overall poor understanding of the relationship between their own health status and the likelihood of a successful CPR attempt. Although healthcare providers offer information and health education in an attempt to address knowledge gaps, these efforts are not always successful or even accepted by residents. Resident viewpoints and priorities differed from healthcare providers in ways that affected communication about CPR. CONCLUSIONS Unrecognised differences in perceptions between providers and residents affect key aspects of ACP communication that can impact CPR decision-making. The concerns and priorities of institutionalized older adults may differ from those of healthcare providers, creating challenges for engaging some residents in ACP. IMPLICATIONS FOR PRACTICE ACP communication models and training should be designed not only to explore nursing facility residents' goals, values, and preferences, but also to elicit any underlying differences in perceptions that may affect communication. Healthcare providers can identifying the primary concerns of residents and assist them with integrating or reframing these issues as a part of ACP discussions.
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Affiliation(s)
- Anne L Myers
- Department of Communication Studies, Indiana University, Indianapolis, Indiana, USA
| | - Marianne S Matthias
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Indiana University School of Medicine, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA
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Bernacki GM, Engelberg RA, Curtis JR, Kurella Tamura M, Brumback LC, Lavallee DC, Vig EK, O’Hare AM. Cardiopulmonary Resuscitation Preferences of People Receiving Dialysis. JAMA Netw Open 2020; 3:e2010398. [PMID: 32833017 PMCID: PMC7445594 DOI: 10.1001/jamanetworkopen.2020.10398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Whether the cardiopulmonary resuscitation (CPR) preferences of patients receiving dialysis align with their values and other aspects of end-of-life care is not known. OBJECTIVE To describe the CPR preferences of patients receiving dialysis and how these preferences are associated with their responses to questions about other aspects of end-of-life care. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey study of a consecutive sample of patients receiving dialysis at 31 nonprofit dialysis facilities in 2 US metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 22, 2015, and October 2, 2018. Analyses for this article were conducted between December 2018 and April 2020. EXPOSURES Participants were asked to respond to the question "If you had to decide right now, would you want CPR if your heart were to stop beating?" Those who indicated they would probably or definitely want CPR were categorized as preferring CPR. MAIN OUTCOMES AND MEASURES This study examined the association between preference for CPR and other treatment preferences, engagement in advance care planning, values, desired place of death, expectations about prognosis, symptoms, and palliative care needs. RESULTS Of the 1434 individuals invited to complete the survey, 1009 agreed to participate, and 876 were included in the analytic cohort (61.1%). The final cohort had a mean (SD) age of 62.6 (14.0) years; 492 (56.2%) were men, and 528 (60.3%) were White individuals. Among 738 of 876 participants (84.2%) who indicated that they would definitely or probably want CPR (CPR group), 555 (75.2%) wanted mechanical ventilation vs 13 of 138 (9.4%) of those who did not want CPR (do not resuscitate [DNR] group) (P < .001). A total of 249 of 738 participants (33.7%) in the CPR group vs 84 of 138 (60.9%) in the DNR group had documented treatment preferences (P < .001). In terms of values about future care, 171 participants (23.2%) in the CPR group vs 5 of 138 (3.6%) in the DNR group valued life prolongation (P < .001); 320 in the CPR group (43.4%) vs 109 of 138 in the DNR group (79.0%) valued comfort (P < .001); and 247 participants (33.5%) in the CPR group vs 24 of 138 (17.4%) in the DNR group were unsure about their wishes for future care (P < .001). In the CPR group, 207 (28.0%) had thought about stopping dialysis vs 62 of 138 (44.9%) in the DNR group (P < .001), and 181 (24.5%) vs 58 of 138 (42.0%) had discussed stopping dialysis (P = .001). No statistically significant associations were observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs. CONCLUSIONS AND RELEVANCE The CPR preferences of patients receiving dialysis were associated with some, but not all, other aspects of end-of-life care. How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR preference. More work is needed to integrate discussions about code status with bigger picture conversations about patients' values, goals, and preferences for end-of-life care.
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Affiliation(s)
- Gwen M. Bernacki
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - J. Randall Curtis
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Manjula Kurella Tamura
- Department of Medicine, Stanford University Medical Center, Palo Alto, California
- Division of Nephrology, Geriatric Research, Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | | | - Elizabeth K. Vig
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Geriatrics, VA Puget Sound Health Care System, Seattle, Washington
| | - Ann M. O’Hare
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle
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Ferrell BR, Chung V, Koczywas M, Smith TJ. Dissemination and Implementation of Palliative Care in Oncology. J Clin Oncol 2020; 38:995-1001. [PMID: 32023151 PMCID: PMC7082157 DOI: 10.1200/jco.18.01766] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 12/24/2022] Open
Abstract
Palliative care began in academic centers with specialty consultation services, and its value to patients, families, and health systems has been evident. The demand for palliative care to be integrated throughout the cancer trajectory, combined with a limited palliative care workforce, means that new models of care are needed. This review discusses evidence regarding the need for integration of palliative care into routine oncology care and describes best practices recognized for dissemination of palliative care. The available evidence suggests that palliative care be widely adopted by clinicians in all oncology settings to benefit patients with cancer and their families. Efforts are needed to adapt and integrate palliative care into community practice. Limitations of these models are discussed, as are future directions to continue implementation efforts. The benefits of palliative care can only be realized through effective dissemination of these principles of care, with more primary palliative care delivered by oncology clinicians.
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Affiliation(s)
| | | | | | - Thomas J. Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, Baltimore, MD
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19
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Hawkes CA, Fritz Z, Deas G, Ahmedzai SH, Richardson A, Pitcher D, Spiller J, Perkins GD. Development of the Recommended Summary Plan for eEmergency Care and Treatment (ReSPECT). Resuscitation 2020; 148:98-107. [PMID: 31945422 DOI: 10.1016/j.resuscitation.2020.01.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/03/2019] [Accepted: 01/02/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) practice has been shown to be variable and sub-optimal. This paper describes the development of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). ReSPECT is a process which encourages shared understanding of a patient's condition and what outcomes they value and fear, before recording clinical recommendations about cardiopulmonary-resuscitation (CPR) within a broader plan for emergency care and treatment. METHODS ReSPECT was developed iteratively, with integral stakeholder engagement, informed by the Knowledge-to-Action cycle. Mixed methods included: synthesis of existing literature; a national online consultation exercise; cognitive interviews with users; a patient-public involvement (PPI) workshop and a usability pilot, to ensure acceptability by both patients and professionals. RESULTS The majority (89%) of consultation respondents supported the concept of emergency care and treatment plans. Key features identified in the evaluation and incorporated into ReSPECT were: The importance of discussions between patient and clinician to inform realistic treatment preferences and clarity in the resulting recommendations recorded by the clinician on the form. The process is compliant with UK mental capacity laws. Documentation should be recognised across all health and care settings. There should be opportunity for timely review based on individual need. CONCLUSION ReSPECT is designed to facilitate discussions about a person's preferences to inform emergency care and treatment plans (including CPR) for use across all health and care settings. It has been developed iteratively with a range of stakeholders. Further research will be needed to assess the influence of ReSPECT on patient-centred decisions, experience and health outcomes.
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Affiliation(s)
- Claire A Hawkes
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, UK
| | - Zoe Fritz
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, UK; Cambridge University Hospitals, UK
| | - Gavin Deas
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
| | - Sam H Ahmedzai
- National Institute for Health Research Clinical Research Network - Cancer Cluster, University of Leeds, UK
| | - Alison Richardson
- School of Health Sciences, University of Southampton & University Hospital Southampton NHS Foundation Trust, UK
| | - David Pitcher
- Resuscitation Council UK, 5th Floor, Tavistock House North, Tavistock Square, London, WC1H 9HR, UK
| | | | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, UK; University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK.
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Abstract
PURPOSE OF REVIEW Tattoos and medallions are examples of nonstandard do-not-resuscitate (DNR) orders that some people use to convey end-of-life wishes. These DNR orders are neither universally accepted nor understood for reasons discussed within this manuscript. RECENT FINDINGS Studies show both providers and patients confuse the meaning and implication of DNR orders. In the United States, out-of-hospital DNR orders are legislated at the state level. Most states standardized out-of-hospital DNR orders so caregivers can immediately recognize and accept the order and act on its behalf. These out-of-hospital orders are complicated by the need to be printed on paper that does not always accompany the individual. Oregon created an online system whereby individuals recorded their end-of-life wishes that medical personnel can access with an Internet connection. This system improved communication of end-of-life wishes in patients who selected comfort care only. SUMMARY To improve conveyance of an individual's wishes for end-of-life care, the authors discuss nationwide adoption of Oregon's online registry where a person's account could comprehensively document end-of-life wishes, be universally available in all healthcare institutions, and be searchable by common patient identifiers. Facial recognition software could identify unconscious patients who present without identification.
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Becker C, Lecheler L, Hochstrasser S, Metzger KA, Widmer M, Thommen EB, Nienhaus K, Ewald H, Meier CA, Rueter F, Schaefert R, Bassetti S, Hunziker S. Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e195033. [PMID: 31173119 PMCID: PMC6563579 DOI: 10.1001/jamanetworkopen.2019.5033] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear. OBJECTIVE To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR. DATA SOURCES PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018. STUDY SELECTION Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. DATA EXTRACTION AND SYNTHESIS The study was performed according to the PRISMA guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment. RESULTS Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71). CONCLUSIONS AND RELEVANCE Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.
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Affiliation(s)
- Christoph Becker
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Leopold Lecheler
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Seraina Hochstrasser
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Kerstin A. Metzger
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Madlaina Widmer
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Emanuel B. Thommen
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Katharina Nienhaus
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Hannah Ewald
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University Medical Library, University of Basel, Basel, Switzerland
| | - Christoph A. Meier
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
- Quality Management, University Hospital Basel, Basel, Switzerland
| | - Florian Rueter
- Quality Management, University Hospital Basel, Basel, Switzerland
| | - Rainer Schaefert
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Clinic for Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication, Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, Coventry, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Zoe Fritz
- The Healthcare Improvement Studies Institute, Cambridge, United Kingdom
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Ahluwalia SC, Chen C, Raaen L, Motala A, Walling AM, Chamberlin M, O'Hanlon C, Larkin J, Lorenz K, Akinniranye O, Hempel S. A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition. J Pain Symptom Manage 2018; 56:831-870. [PMID: 30391049 DOI: 10.1016/j.jpainsymman.2018.09.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/07/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers. OBJECTIVES The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care. METHODS Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel. RESULTS We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews). CONCLUSION A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.
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Affiliation(s)
- Sangeeta C Ahluwalia
- RAND Health, Santa Monica, California, USA; UCLA Fielding School of Public Health, Los Angeles, California, USA.
| | - Christine Chen
- Pardee RAND Graduate School, Santa Monica, California, USA
| | | | - Aneesa Motala
- Evidence based Practice Center, RAND Corp., Santa Monica, California, USA
| | - Anne M Walling
- RAND Health, Santa Monica, California, USA; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA
| | | | | | - Jody Larkin
- Evidence based Practice Center, RAND Corp., Santa Monica, California, USA
| | - Karl Lorenz
- RAND Health, Santa Monica, California, USA; VA Palo Alto Health Care System, Center for Innovation to Implementation, Menlo Park, California, USA; Stanford University School of Medicine, Stanford, California, USA
| | | | - Susanne Hempel
- Evidence based Practice Center, RAND Corp., Santa Monica, California, USA
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Johnson CE, Chong JC, Wilkinson A, Hayes B, Tait S, Waldron N. Goals of patient care system change with video-based education increases rates of advance cardiopulmonary resuscitation decision-making and discussions in hospitalised rehabilitation patients. Intern Med J 2018; 47:798-806. [PMID: 28401688 DOI: 10.1111/imj.13454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/23/2017] [Accepted: 04/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR. AIM To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients. METHODS A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer. RESULTS When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03). CONCLUSION An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care.
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Affiliation(s)
- Claire E Johnson
- School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - Jeffrey C Chong
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia
| | - Anne Wilkinson
- School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Barbara Hayes
- Advance Care Planning Program, Northern Health, Melbourne, Victoria, Australia.,Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sonia Tait
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia
| | - Nicholas Waldron
- Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia.,Health Strategy and Networks, System Policy and Planning, Department of Health, Government of Western Australia, Perth, Western Australia, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
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Richardson-Royer C, Naqvi I, Riffel C, Harvey L, Smith D, Ayalew D, Motayar N, Amoateng-Adjepong Y, Manthous CA. A video depicting resuscitation did not impact upon patients' decision-making. Int J Gen Med 2018; 11:73-77. [PMID: 29491715 PMCID: PMC5815506 DOI: 10.2147/ijgm.s147109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Previous studies have demonstrated that video of and scripted information about cardiopulmonary resuscitation (CPR) can be deployed during clinician–patient end-of-life discussions. Few studies, however, examine whether video adds to verbal information-sharing. We hypothesized that video augments script-only decision-making. Methods Patients aged >65 years admitted to hospital wards were randomized to receive evidence-based information (“script”) vs. script plus video of simulated CPR and intubation. Patients’ decisions registered in the hospital record, by hospital discharge were compared for the two groups. Results Fifty script-only intervention patients averaging 77.7 years were compared to 50 script+video patients with a mean age of 74.7 years. Eleven of 50 (22%) in each group declined CPR; and an additional three (script) vs. four (script+video) refused intubation for respiratory failure. There were no differences in sex, self-reported health trajectory, functional limitations, length of stay, or mortality associated with decisions. Conclusion The rate at which verbally informed hospitalized elders opted out of resuscitation was not impacted by adding a video depiction of CPR.
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Affiliation(s)
| | - Imran Naqvi
- The Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | | | | | | | | | - Nasim Motayar
- The Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Yaw Amoateng-Adjepong
- The Jewish Hospital of Cincinnati, Cincinnati, OH, USA.,Yale University School of Medicine, New Haven, CT, USA
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Cummings A, Lund S, Campling N, May C, Richardson A, Myall M. Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review. BMJ Open 2017; 7:e017056. [PMID: 28988176 PMCID: PMC5640076 DOI: 10.1136/bmjopen-2017-017056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration. DESIGN AND METHODS A scoping review was undertaken based on the methodological framework of Arksey and O'Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes. RESULTS Searches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal. CONCLUSIONS A broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions.
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Affiliation(s)
- Amanda Cummings
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Susi Lund
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Natasha Campling
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
- University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Michelle Myall
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
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Malyon AC, Forman JR, Fuld JP, Fritz Z. Discussion and documentation of future care: a before-and-after study examining the impact of an alternative approach to recording treatment decisions on advance care planning in an acute hospital. BMJ Support Palliat Care 2017; 10:e12. [PMID: 28864448 DOI: 10.1136/bmjspcare-2016-001101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/08/2017] [Accepted: 05/15/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether discussion and documentation of decisions about future care was improved following the introduction of a new approach to recording treatment decisions: the Universal Form of Treatment Options (UFTO). METHODS Retrospective review of the medical records of patients who died within 90 days of admission to oncology or respiratory medicine wards over two 3-month periods, preimplementation and postimplementation of the UFTO. A sample size of 70 per group was required to provide 80% power to observe a change from 15% to 35% in discussion or documentation of advance care planning (ACP), using a two-sided test at the 5% significance level. RESULTS On the oncology ward, introduction of the UFTO was associated with a statistically significant increase in cardiopulmonary resuscitation decisions documented for patients (pre-UFTO 52% to post-UFTO 77%, p=0.01) and an increase in discussions regarding ACP (pre-UFTO 27%, post-UFTO 49%, p=0.03). There were no demonstrable changes in practice on the respiratory ward. Only one patient came into hospital with a formal ACP document. CONCLUSIONS Despite patients' proximity to the end-of-life, there was limited documentation of ACP and almost no evidence of formalised ACP. The introduction of the UFTO was associated with a change in practice on the oncology ward but this was not observed for respiratory patients. A new approach to recording treatment decisions may contribute to improving discussion and documentation about future care but further work is needed to ensure that all patients' preferences for treatment and care at the end-of-life are known.
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Affiliation(s)
- Alexandra C Malyon
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Julia R Forman
- Applied Statistics and Epidemiology, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jonathan P Fuld
- Respiratory and Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zoë Fritz
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust and Warwick University, UK
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bossaert L, Perkins G, Askitopoulou H, Raffay V, Greif R, Haywood K, Mentzelopoulos S, Nolan J, Van de Voorde P, Xanthos T. Ethik der Reanimation und Entscheidungen am Lebensende. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0329-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gulacti U, Lok U. Influences of "do-not-resuscitate order" prohibition on CPR outcomes. Turk J Emerg Med 2016; 16:47-52. [PMID: 27896320 PMCID: PMC5121282 DOI: 10.1016/j.tjem.2016.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/15/2016] [Accepted: 03/23/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of the study is to determine factors affecting the return of spontaneous circulation (ROSC) ratios, neurological outcomes at discharge, the ratio of living patients discharged from the hospital and due to Do not attempt resuscitation (DNAR) prohibition. MATERIAL AND METHODS This is a retrospective observational study conducted on patients of cardiopulmonary resuscitation (CPR) performed in emergency department (ED) and intensive care units between February 2010 and February 2012. RESULTS A total of 469 patients were evaluated, and 266 eligible patients who did not have DNAR orders were included in the study. Overall, 45.1% of the adult in-hospital cardiac arrest victims returned to spontaneous circulation, and 5.3% survived to hospital discharge. Of the patients who were discharged alive from the hospital, 33.3% were discharged in poor neurologic conditions of Cerebral Performance Category (CPC) score 3 or 4. The ROSC ratio was reduced for the patients with malignancies compared to the patients with other preexisting conditions (OR: 12.783; 95% CI 2.967-55.072; p = 0.000). None of the patients with malignancies were discharged alive from the hospital. Only one patient with end-stage disease was discharged alive from hospital, and this patient's CPC score was 4. DISCUSSION AND CONCLUSION CPR has not increased the ROSC and alive discharge rates in patients with malignancy and end-state disease. DNAR order prohibition have been increased the futile CPR attempts. DNAR should be accepted as a human right that represents an honorable death option and whether a DNAR is order demanded should be specifically discussed with patients with malignancies and end-stage disease presenting to ED.
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Affiliation(s)
- Umut Gulacti
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
| | - Ugur Lok
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
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Ruiz-García J, Canal-Fontcuberta I, Martínez-Sellés M. Las órdenes de no reanimar. Historia y situación actual. Med Clin (Barc) 2016; 147:316-20. [DOI: 10.1016/j.medcli.2016.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 12/21/2022]
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 923] [Impact Index Per Article: 115.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Perkins GD, Griffiths F, Slowther AM, George R, Fritz Z, Satherley P, Williams B, Waugh N, Cooke MW, Chambers S, Mockford C, Freeman K, Grove A, Field R, Owen S, Clarke B, Court R, Hawkes C. Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Gavin D Perkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Robert George
- Cicely Saunders Institute, King’s College London, London, UK
- Palliative Care, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Zoe Fritz
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Barry Williams
- Patient and Relative Committee, The Intensive Care Foundation, London, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew W Cooke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sue Chambers
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carole Mockford
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Grove
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard Field
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sarah Owen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Clarke
- Medical School, University of Glasgow, Glasgow, UK
| | - Rachel Court
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Hawkes
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Ethik der Reanimation und Entscheidungen am Lebensende. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0083-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Bossaert LL, Perkins GD, Askitopoulou H, Raffay VI, Greif R, Haywood KL, Mentzelopoulos SD, Nolan JP, Van de Voorde P, Xanthos TT, Georgiou M, Lippert FK, Steen PA. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:302-11. [DOI: 10.1016/j.resuscitation.2015.07.033] [Citation(s) in RCA: 256] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Limitation of care orders in patients with a diagnosis of dementia. Resuscitation 2015; 98:118-24. [PMID: 25818706 DOI: 10.1016/j.resuscitation.2015.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/11/2015] [Accepted: 03/16/2015] [Indexed: 11/22/2022]
Abstract
The prevalence of dementia is growing with an ageing population. Most persons with dementia die of acute illness and many are hospitalised at the end of life. In the acute hospital setting, limitation of care orders (LCOs) such as Do Not Attempt CPR and Physician Orders For Life Sustaining Treatment (POLST), appear to be underused in patients with dementia. These patients receive the same aggressive life-prolonging therapies as any other patient, despite drastically higher mortality. However, limitation of care orders in patients with dementia is not addressed by current guidelines or policies. Systems and processes for obtaining and documenting LCO need improvement at the individual, organisational and societal level. The issue is controversial amongst the public and poorly understood by clinicians. Balanced and empathetic decision-making requires an individualised approach and recognition of the complexities (legal, ethical and clinical) of this issue. We examine the domains of: (a) treatment effectiveness, (b) burden of care and quality of life and (c) patient autonomy and capacity.
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Mockford C, Fritz Z, George R, Court R, Grove A, Clarke B, Field R, Perkins GD. Do not attempt cardiopulmonary resuscitation (DNACPR) orders: A systematic review of the barriers and facilitators of decision-making and implementation. Resuscitation 2015; 88:99-113. [DOI: 10.1016/j.resuscitation.2014.11.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 11/14/2014] [Accepted: 11/18/2014] [Indexed: 12/21/2022]
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Shif Y, Doshi P, Almoosa KF. What CPR means to surrogate decision makers of ICU patients. Resuscitation 2015; 90:73-8. [PMID: 25711518 DOI: 10.1016/j.resuscitation.2015.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 02/04/2015] [Accepted: 02/08/2015] [Indexed: 11/24/2022]
Abstract
AIM OF THE STUDY The decision to accept or decline cardiopulmonary resuscitation (CPR) by surrogate decision makers on behalf of a family member is a common and important component of end-of-life decision-making in the ICU. While many determinants influence this decision, surrogates' understanding of CPR may be a major guiding factor. However, little is known about surrogates' knowledge and perceptions of CPR during the periods of time when their family member is critically ill. We conducted this study to explore surrogates' understanding of some basic concepts of CPR. METHODS This is a descriptive, survey-based exploratory study of understanding of CPR concepts and outcomes conducted in a single-center medical ICU at a tertiary academic hospital in the United States. Study subjects were surrogate decision-makers of critically ill ICU patients who participated in an interview-format survey within 24h of the patient's ICU admission. RESULTS Of 97 eligible subjects (surrogates), 50 were enrolled in this study and represented a wide spectrum of demographics. All subjects had heard of CPR. The main source of information about CPR was a course. While 46% identified cardiac arrest as a main indication for CPR, only 8% identified at least 2 of the 3 main components of CPR. The majority (72%) believed survival after CPR was ≥75%. Forty-two percent of surrogates had spoken to the patient about CPR prior to coming to the hospital, and 57% had spoken to the physician during this hospitalization. Twenty-six percent changed their decision on CPR during the ICU stay. CONCLUSION There is a wide variation in surrogates' understanding and knowledge of CPR concepts and outcomes.
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Affiliation(s)
- Yuri Shif
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, United States.
| | - Pratik Doshi
- University of Texas Health Science Center, Houston, United States.
| | - Khalid F Almoosa
- University of Texas Health Science Center, Houston, United States.
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Freeman K, Field RA, Perkins GD. Variation in local trust Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies: a review of 48 English healthcare trusts. BMJ Open 2015; 5:e006517. [PMID: 25586369 PMCID: PMC4298091 DOI: 10.1136/bmjopen-2014-006517] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 10/03/2014] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies from English acute, community and ambulance service Trusts for evidence of consistency and variation in implementation of national guidelines between healthcare organisations. SETTING Acute, community or ambulance National Health Service (NHS) Trusts in England. PARTICIPANTS 48 NHS Trusts. INTERVENTIONS Freedom of information requests for adult DNACPR policies were sent to a random sample of Trusts. OUTCOMES DNACPR policies were assessed on aspects identified from national guidelines including documentation, ethical and legal issues, decision-makers and involvement of others in DNACPR decisions as well as practical considerations such as validity, review and portability of decisions. RESULTS Policies from 26 acute, 12 community and 10 ambulance service Trusts were reviewed. There was variation in terminology used (85% described documents as policies, 6% procedures and 8% guidelines). Only one quarter of Trusts used the recommended Resuscitation Council (UK) record form (or a modification of the form). There was variation in the terminology used which included DNAR, DNACPR, Not for CPR and AND (allow natural death). Accountability for DNACPR decisions rested with consultants at all acute Trusts and the most senior clinician at community Trusts. Most Trusts (74%) recommended discussion of decisions with a multidisciplinary team. Compliance with guidance requiring clinical staff to assess the patient for capacity and when to consult a lasting power of attorney or independent mental capacity advocate occurred less commonly. There was wide variation in the duration of time over which a DNACPR decision was considered valid as well as in the Trusts' approach to reviewing DNACPR decisions. The level of portability of DNACPR decisions between healthcare organisations was one of the greatest sources of variation. CONCLUSIONS There is significant variation in the translation of the national DNACPR guidelines into English healthcare Trusts' DNACPR policies.
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Affiliation(s)
- Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard A Field
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, UK
| | - Gavin D Perkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, UK
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Sundar S, Do J, O’Cathail M. Misconceptions about ‘do-not-resuscitate (DNR)’ orders in the era of social media. Resuscitation 2015; 86:e3. [DOI: 10.1016/j.resuscitation.2014.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 10/26/2014] [Indexed: 11/15/2022]
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Mancini ME. It's time to understand the dynamics of "do not attempt cardiopulmonary resuscitation" orders. Resuscitation 2014; 88:A1-2. [PMID: 25530358 DOI: 10.1016/j.resuscitation.2014.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/11/2014] [Indexed: 11/26/2022]
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‘Do not attempt cardiopulmonary resuscitation’ or ‘allowing natural death’? The time for resuscitation community to review its boundaries and its terminology. Resuscitation 2014; 85:1644-5. [DOI: 10.1016/j.resuscitation.2014.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/14/2014] [Indexed: 11/21/2022]
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