The effect of do-not-resuscitate orders on physician decision-making

Misunderstandings of "do not attempt resuscitation" orders among physicians and nurses' perceptions: A questionnaire survey in Japan

AIM

This study aimed to clarify the current understanding/misunderstanding regarding the "do not attempt resuscitation (DNAR)" order among physicians and nurses in Japan as well as related factors.

METHODS

We conducted a questionnaire survey of physicians and nurses working in three Japanese medical institutions. We established "misconception indicators" for DNAR orders and identified related factors using the Mann-Whitney U test, with multiple comparisons using the Dunn test. Differences in each misconception indicator were compared between physicians and nurses using the chi-square test.

RESULTS

We obtained survey responses from 134 physicians and 233 nurses. Among them, >70% of physicians and nurses responded that a DNAR order indicated withholding invasive medical care. Moreover, responses suggesting that DNAR prompted palliative care were more common among physicians and nurses working at hospitals without intensive care units or rapid response systems. Additionally, >40% of physicians responded that a DNAR order prompted them to limit the use of medical resources, including the intensive care unit and blood transfusions, with this proportion being higher than that among nurses. Further, physicians with longer clinical experience were more likely to limit the use of medical resources in cases of a DNAR order.

CONCLUSIONS

Many physicians and nurses misinterpreted a DNAR order as prompting palliative care. To facilitate support toward patient decision-making and correct implementation of DNAR orders, it is important to establish internal guidelines, provide education regarding end-of-life care and medical terminology, and introduce specialized care teams. Geriatr Gerontol Int 2025; ••: ••-••.

EMPOWERING END-OF-LIFE CONVERSATIONS: The Role of Specialized Nursing Teams in Facilitating Code Status Changes at Discharge

Objectives: Hospitalized patients may require goals of care (GOC) or Advance Health Care Planning (ACP), which can be time-consuming and emotionally tolling for providers. A nursing team specializing in code status (CODE), GOC, and ACP was developed to provide meaningful support for patients and families and decrease provider burden. Interest in CODE, GOC, ACP, and effectiveness of a nursing team to lead these conversations prompted this study. Methods: A collaborative nursing team was trained to address CODE, GOC, and ACP with patients demonstrating illness or geriatric syndrome. This team conducted 3 visits per patient on average during hospitalization using structured CODE templates to establish longer term goals and document what matters in the healthcare journey. Comprehensive narratives for ACP and GOC were included in charting, syncing the medical team, nursing, patient, and family. Consults were tracked over nine months with data reviewed retrospectively from medical charts. Descriptive analyses of cohort demographics, CODE and outcomes were completed. Results: The study group comprised 3342 patients between October 2022 and June 2023. Patients ranged in age from 18-106 years, with majority (88%) age 65 years and older. Mean length of stay (LOS) was 6.8 days with CODE documented for 91% upon admission. Of the 3166 older adults with known CODE on admission, 946 (30%) changed CODE by discharge, of which 95% were de-escalated. 83% of older patients arriving with limited CODE maintained limitations at discharge, with a small portion converting to comfort (16%). Conclusion: Employing a focused nursing team to conduct CODE, GOC, and ACP conversations may be an effective use of time and resources and result in de-escalation of resuscitation orders for patients demonstrating illness or geriatric syndrome.

Pathophysiology of Intracerebral Hemorrhage: Recovery Trajectories

Recovery trajectories in intracerebral hemorrhage (ICH) are recognized as distinct from those observed in ischemic stroke. This narrative review aims to clarify the pathophysiology underlying ICH recovery patterns, highlighting the unique timeline and nature of functional improvements seen in ICH survivors. Population-based cohort studies tracking functional outcomes in a longitudinal fashion, along with randomized clinical trial data with standardized outcome assessments, have demonstrated that ICH recovery generally has a delayed onset in the first weeks, followed by a steep early subacute stage recovery (typically up to 3 months) continuing in protracted, gradual improvements beyond 3 to 6 months. Understanding these recovery patterns, and how these differ from ischemic stroke, is crucial for providing accurate prognostic information, facilitating targeted health care delivery, and optimizing therapeutic interventions and the design of ICH randomized trials. This article synthesizes current evidence on early- and late-stage functional recovery trajectories in primary, spontaneous ICH and cognitive outcomes, emphasizing the clinical and research implications of these recovery patterns.

Using the Recommended Summary Plan for Emergency Care and Treatment in Primary Care: a mixed methods study

Background

Emergency care treatment plans provide recommendations about treatment, including cardiopulmonary resuscitation, to be considered in emergency medical situations. In 2016, the Resuscitation Council United Kingdom developed a standardised emergency care treatment plan, the recommended summary plan for emergency care and treatment, known as ReSPECT. There are advantages and potential difficulties in initiating the ReSPECT process in primary care. Hospital doctors and general practitioners may use the process differently and recommendations do not always translate between settings. There are no large studies of the use of ReSPECT in the community.

Study aim

To evaluate how, when and why ReSPECT is used in primary care and what effect it has on patient treatment and care.

Design

A mixed-methods approach using interviews, focus groups, surveys and evaluation of ReSPECT forms within an analytical framework of normalisation process theory.

Setting

A total of 13 general practices and 13 care homes across 3 areas of England.

Participants

General practitioners, senior primary care nurses, senior care home staff, patients and their relatives, community and emergency department clinicians and home care workers, people with learning disability and their carers. National surveys of (1) the public and (2) general practitioners.

Results

Members of the public are supportive of emergency care treatment plans. Respondents recognised benefits of plans but also potential risks if the recommendations become out of date. The ReSPECT plans were used by 345/842 (41%) of general practitioner survey respondents. Those who used ReSPECT were more likely to be comfortable having emergency care treatment conversations than respondents who used standalone 'do not attempt cardiopulmonary resuscitation' forms. The recommended summary plan for emergency care and treatment was conceptualised by all participants as person centred, enabling patients to have some say over future treatment decisions. Including families in the discussion is seen as important so they know the patient's wishes, which facilitates decision-making in an emergency. Writing recommendations is challenging because of uncertainty around future clinical events and treatment options. Care home staff described conflict over treatment decisions with clinicians attending in an emergency, with treatment decisions not always reflecting recommendations. People with a ReSPECT plan and their relatives trusted that recommendations would be followed in an emergency, but carers of people with a learning disability had less confidence that this would be the case. The ReSPECT form evaluation showed 87% (122/141) recorded free-text treatment recommendations other than cardiopulmonary resuscitation. Patient preferences were recorded in 57% (81/141). Where a patient lacked capacity the presence of a relative or lasting power of attorney was recorded in two-thirds of forms.

Limitations

Recruitment for patient/relative interviews was less than anticipated so caution is required in interpreting these data. Minority ethnic groups were under-represented across our studies.

Conclusions

The aims of ReSPECT are supported by health and social care professionals, patients, and the public. Uncertainty around illness trajectory and treatment options for a patient in a community setting cannot be easily translated into specific recommendations. This can lead to conflict and variation in how recommendations are interpreted.

Future work

Future research should explore how best to integrate patient values into treatment decision-making in an emergency.

Study registration

This study is registered as NCT05046197.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131316) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 42. See the NIHR Funding and Awards website for further award information.

Public attitudes to emergency care treatment plans: a population survey of Great Britain

OBJECTIVES

To measure community attitudes to emergency care and treatment plans (ECTPs).

DESIGN

Population survey.

SETTING

Great Britain.

PARTICIPANTS

As part of the British Social Attitudes Survey, sent to randomly selected addresses in Great Britain, 1135 adults completed a module on ECTPs. The sample was nationally representative in terms of age and location, 619 (55%) were female and 1005 (89%) were of white origin.

OUTCOME MEASURES

People's attitudes having an ECTP for themselves now, and in the future; how comfortable they might be having a discussion about an ECTP and how they thought such a plan might impact on their future care.

RESULTS

Predominantly, respondents were in favour of people being able to have an ECTP, with 908/1135 (80%) being at least somewhat in favour. People in good health were less likely than those with activity-limiting chronic disease to want a plan at present (52% vs 64%, OR 1.78 (95% CI 1.30 to 2.45) p<0.001). Developing a long-term condition or becoming disabled would lead 42% (467/1112) and 43% (481/1112) of individuals, respectively, to want an ECTP. More, 634/1112 (57%) would want an ECTP if they developed a life-threatening condition. Predominantly, 938/1135 (83%) respondents agreed that an ECTP would help avoid their family needing to make difficult decisions on their behalf, and 939/1135 (83%) that it would ensure doctors and nurses knew their wishes. Nevertheless, a small majority-628/1135 (55%)-agreed that there was a serious risk of the plan being out of date when needed. A substantial minority-330/1135 (29%)-agreed that an ECTP might result in them not receiving life-saving treatment.

CONCLUSIONS

There is general support for the use of ECTPs by people of all ages. Nevertheless, many respondents felt these might be out of date when needed and prevent people receiving life-saving treatment.

GPs' views on emergency care treatment plans: an online survey

BACKGROUND

A holistic approach to emergency care treatment planning is needed to ensure that patients' preferences are considered should their clinical condition deteriorate. To address this, emergency care and treatment plans (ECTPs) have been introduced. Little is known about their use in general practice.

AIM

To find out GPs' experiences of, and views on, using ECTPs.

DESIGN & SETTING

Online survey of GPs practising in England.

METHOD

A total of 841 GPs were surveyed using the monthly online survey provided by medeConnect, a market research company.

RESULTS

Forty-one per cent of responders' practices used Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans for ECTP, 8% used other ECTPs, and 51% used Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms. GPs were the predominant professional group completing ECTPs in the community. There was broad support for a wider range of community-based health and social care professionals being able to complete ECTPs. There was no system for reviewing ECTPs in 20% of responders' practices. When compared with using a DNACPR form, GPs using a ReSPECT form for ECTP were more comfortable having conversations about emergency care treatment with patients (odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.1 to 2.69) and family members (OR =1.85, 95% CI = 1.19 to 2.87).

CONCLUSION

The potential benefits and challenges of widening the pool of health and social care professionals initiating and/or completing the ECTP process needs consideration. ReSPECT plans appear to make GPs more comfortable with ECTP discussions, supporting their implementation. Practice-based systems for reviewing ECTP decisions should be strengthened.

Prognostic models of in-hospital mortality of intensive care patients using neural representation of unstructured text: A systematic review and critical appraisal

OBJECTIVE

To review and critically appraise published and preprint reports of prognostic models of in-hospital mortality of patients in the intensive-care unit (ICU) based on neural representations (embeddings) of clinical notes.

METHODS

PubMed and arXiv were searched up to August 1, 2022. At least two reviewers independently selected the studies that developed a prognostic model of in-hospital mortality of intensive-care patients using free-text represented as embeddings and extracted data using the CHARMS checklist. Risk of bias was assessed using PROBAST. Reporting on the model was assessed with the TRIPOD guideline. To assess the machine learning components that were used in the models, we present a new descriptive framework based on different techniques to represent text and provide predictions from text. The study protocol was registered in the PROSPERO database (CRD42022354602).

RESULTS

Eighteen studies out of 2,825 were included. All studies used the publicly-available MIMIC dataset. Context-independent word embeddings are widely used. Model discrimination was provided by all studies (AUROC 0.75-0.96), but measures of calibration were scarce. Seven studies used both structural clinical variables and notes. Model discrimination improved when adding clinical notes to variables. None of the models was externally validated and often a simple train/test split was used for internal validation. Our critical appraisal demonstrated a high risk of bias in all studies and concerns regarding their applicability in clinical practice.

CONCLUSION

All studies used a neural architecture for prediction and were based on one publicly available dataset. Clinical notes were reported to improve predictive performance when used in addition to only clinical variables. Most studies had methodological, reporting, and applicability issues. We recommend reporting both model discrimination and calibration, using additional data sources, and using more robust evaluation strategies, including prospective and external validation. Finally, sharing data and code is encouraged to improve study reproducibility.

Code status orders in hospitalized patients with COVID-19

Background

The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19.

Methods

A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020).

Results

Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80.

Conclusions

There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.

Socio-economic determinants for the place of last care: results from the acute palliative care unit of a large comprehensive cancer center in a high-income country in Europe

BACKGROUND AND INTRODUCTION

The place of last care carries importance for patients at the end of life. It is influenced by the realities of the social welfare and healthcare systems, cultural aspects, and symptom burden. This study aims to investigate the place of care trajectories of patients admitted to an acute palliative care unit.

MATERIALS AND METHODS

The medical records of all patients hospitalized on our acute palliative care unit in 2019 were assessed. Demographic, socio-economic and disease characteristics were recorded. Descriptive and inferential statistics were used to identify determinants for place of last care.

RESULTS

A total of 377 patients were included in this study. Median age was 71 (IQR, 59-81) years. Of these patients, 56% (n = 210) were male. The majority of patients was Swiss (80%; n = 300); about 60% (n = 226) reported a Christian confession; and 77% had completed high school or tertiary education. Most patients (80%, n = 300) had a cancer diagnosis. The acute palliative care unit was the place of last care for 54% of patients. Gender, nationality, religion, health insurance, and highest level of completed education were no predictors for place of last care, yet previous outpatient palliative care involvement decreased the odds of dying in a hospital (OR, 0.301; 95% CI, 0.180-0.505; p-value < 0.001).

CONCLUSION

More than half of patients admitted for end-of-life care died on the acute palliative care unit. While socio-economic factors did not determine place of last care, previous involvement of outpatient palliative care is a lever to facilitate dying at home.

Code Status Orders: Do the Options Matter?

BACKGROUND

Code status orders in hospitalized patients guide urgent medical decisions. Inconsistent terminology and treatment options contribute to varied interpretations.

OBJECTIVE

To compare two code status order options, traditional (three option) and modified to include additional care options (four option).

DESIGN

Prospective, randomized, cross-sectional survey conducted on February-March 2020. Participants were provided with six clinical scenarios and randomly assigned to the three or four option code status order. In three scenarios, participants determined the most appropriate code status. Three scenarios provided clinical details and code status and respondents were asked whether they would provide a particular intervention. This study was conducted at three urban, academic hospitals.

PARTICIPANTS

Clinicians who routinely utilize code status orders. Of 4006 participants eligible, 549 (14%) were included.

MAIN MEASURES

The primary objective was consensus (most commonly selected answer) based on provided code status options. Secondary objectives included variables associated with participant responses, participant code status model preference, and participant confidence about whether their selections would match their peers.

KEY RESULTS

In the three scenarios participants selected the appropriate code status, there was no difference in consensus for the control scenario, and higher consensus in the three option group (p-values < 0.05) for the remaining two scenarios. In the scenarios to determine if a clinical intervention was appropriate, two of the scenarios had higher consensus in the three option group (p-values 0.018 and < 0.05) and one had higher consensus in the four option group (p-value 0.001). Participants in the three option model were more confident that their peers selected the same code status (p-value 0.0014); however, most participants (72%) preferred the four option model.

CONCLUSIONS

Neither code status model led to consistent results. The three option model provided consistency more often; however, the majority of participants preferred the four option model.

Do-Not-Resuscitate Orders and Outcomes for Patients with Pancreatic Cancer

Background

The impact of the do-not-resuscitate (DNR) order on patients with pancreatic cancer remains uncertain. In this study, we evaluated whether DNR status was associated with in-hospital mortality and costs for inpatient stay among patients hospitalized with pancreatic cancer.

Methods

Data were obtained from the National Inpatient Sample, Healthcare Cost and Utilization Project, which represents ∼20% of all discharges from US community hospitals; 40,246 pancreatic cancer admissions between 2011 and 2016 were included. Mortality was modeled using a logistic regression model; costs for inpatient stay were modeled using a multivariable generalized linear regression model.

Results

The sample included 6041 (15%) patients with a documented DNR order. After controlling for covariates, patients with a DNR order had approximately six times greater odds of mortality compared with patients without a DNR order (odds ratio 5.90, p < 0.0001). Compared with patients who survived without a DNR order during the hospital stay, patients who had a DNR order and died during the hospital stay had significantly lower costs (-US$983; p = 0.0270), and patients who died without a DNR order during the hospital stay had significantly higher costs (US$5638; p < 0.0001). Patients who survived with a DNR order had costs that were not significantly different from patients who survived without a DNR order.

Conclusions

The presence of a DNR order among patients with pancreatic cancer was significantly associated with higher mortality risk as well as lower costs for patients who died during the hospital stay. However, DNR status was not significantly associated with costs for pancreatic cancer patients who were discharged alive.

Racial and Ethnic Differences in the Prevalence of Do-Not-Resuscitate Orders among Older Adults with Severe Traumatic Brain Injury

Background

Older adults suffering from traumatic brain injury (TBI) are subject to higher injury burden and mortality. Do Not Resuscitate (DNR) orders are used to provide care aligned with patient wishes, but they may not be equitably distributed across racial/ethnic groups. We examined racial/ethnic differences in the prevalence of DNR orders at hospital admission in older patients with severe TBI.

Methods

We conducted a retrospective cohort study using the National Trauma Databank (NTDB) between 2007 to 2016. We examined patients ≥ 65 years with severe TBI. For our primary aim, the exposure was race/ethnicity and outcome was the presence of a documented DNR at hospital admission. We conducted an exploratory analysis of hospital outcomes including hospital mortality, discharge to hospice, and healthcare utilization (intracranial pressure monitor placement, hospital LOS, and duration of mechanical ventilation).

Results

Compared to White patients, Black patients (OR 0.48, 95% CI 0.35-0.64), Hispanic patients (OR 0.54, 95% CI 0.40-0.70), and Asian patients (OR 0.63, 95% CI 0.44-0.90) had decreased odds of having a DNR order at hospital admission. Patients with DNRs had increased odds of hospital mortality (OR 2.16, 95% CI 1.94-2.42), discharge to hospice (OR 2.08, 95% CI 1.75-2.46), shorter hospital LOS (−2.07 days, 95% CI −3.07 to −1.08) and duration of mechanical ventilation (−1.09 days, 95% CI −1.52 to −0.67). There was no significant difference in the utilization of ICP monitoring (OR 0.94, 95% CI 0.78-1.12).

Conclusions

We found significant racial and ethnic differences in the utilization of DNR orders among older patients with severe TBI. Additionally. DNR orders at hospital admission were associated with increased in-hospital mortality, increased hospice utilization, and decreased healthcare utilization. Future studies should examine mechanisms underlying race-based differences in DNR utilization.

Early DNR in Older Adults Hospitalized with SARS-CoV-2 Infection During Initial Pandemic Surge

The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8, P < .001), women (51.2% vs 43.6%, P = .012), with higher comorbidity index (3.88 vs 3.36, P < .001), facility-based (49.1% vs 19.1%, P < .001), with dementia (13.3% vs 4.6%, P < .001), and severely ill on presentation (57.9% vs 32.3%, P < .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10-4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40-.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21-.67), and shorter length of stay (LOS, 4.8 vs 10.3 days, P < .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85-1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40-.75), IMV (OR: 0.53, 95% CI: 0.29-.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30-.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.

The Impact of Do-Not-Resuscitate Order in the Emergency Department on Respiratory Failure after ICU Admission

(1) Background: It has been hypothesized that a discrepancy exists in the understanding of a do-not-resuscitate (DNR) order among physicians. We hypothesized that a DNR order signed in the emergency department (ED) could influence the patients’ prognosis after intensive care unit (ICU) admission. (2) Methods: We included patients older than 17 years, who visited the emergency department for non-traumatic disease, who had respiratory failure, required ventilator support, and were admitted to the ICU between January 2010 and December 2016. The associations between DNR and mortality, hospital length of stay (LOS), and medical fees were analyzed. Prolonged hospital LOS was defined as hospital stay ≥75th percentile (≥26 days for the study). Patients were classified as those who did and did not sign a DNR order. A 1:4 propensity score matching was conducted for demographics, comorbidities, and etiology. (3) Results: The study enrolled a total of 1510 patients who signed a DNR and 6040 patients who did not sign a DNR. The 30-day mortality rates were 47.4% and 28.0% among patients who did and did not sign a DNR, respectively. A DNR order was associated with mortality after adjusting for confounding factors (hazard ratio, 1.9; confidence interval, 1.70−2.03). It was also a risk factor for prolonged hospital LOS in survivors (odds ratio, 1.2; confidence interval, 1.02−1.44). Survivors who signed a DNR order were charged higher medical fees than those who did not sign a DNR (217,159 vs. 245,795 New Taiwan Dollars, p < 0.001). (4) Conclusions: Signing a DNR order in the ED increased the ICU mortality rate among patients who had respiratory failure and needed ventilator support. It increased the risk of prolonged hospital LOS among survivors. Finally, signing a DNR order was associated with high medical fees among survivors.

Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act

Background

Methods

Results

Conclusions

Predictors, Treatments, and Outcomes of Do-Not-Resuscitate Status in Acute Myocardial Infarction Patients (from a Nationwide Inpatient Cohort Study)

Little is known about how frequently do-not-resuscitate (DNR) orders are placed in patients with acute myocardial infarction (AMI), the types of patients in which they are placed, treatment strategies or clinical outcomes of such patients. Using the United States (US) National Inpatient Sample (NIS) database from 2015 to 2018, we identified 2,767,549 admissions that were admitted to US hospitals and during the hospitalization received a principle diagnosis of AMI, of which 339,270 (12.3%) patients had a DNR order (instigated both preadmission and during in-hospital stay). Patients with a DNR status were older (median age 83 vs 65, p < 0.001), more likely to be female (53.4% vs 39.3%, p < 0.001) and White (81.0% vs 73.3%, p < 0.001). Predictors of DNR status included comorbidities such as heart failure (OR: 1.47, 95% CI: 1.45 to 1.48), dementia (OR: 2.53, 95% CI: 2.50 to 2.55), and cancer. Patients with a DNR order were less likely to undergo invasive management or be discharged home (13.5% vs 52.8%), with only 1/3 receiving palliative consultation. In hospital mortality (32.7% vs 4.6%, p < 0.001) and MACCE (37.1% vs 8.8%, p < 0.001) were higher in the DNR group. Factors independently associated with in-hospital mortality among patients with a DNR order included a STEMI presentation (OR: 2.90, 95% CI: 2.84 to 2.96) and being of Black (OR: 1.29, 95% CI: 1.26 to 1.33), Hispanic (OR: 1.36, 95% CI: 1.32 to 1.41) or Asian/Pacific Islander (OR: 1.56, 95% CI:1.49-race. In conclusion, AMI patients with a DNR status were older, multimorbid, less likely to receive invasive management, with only one third of patients with DNR status referred for palliative care.

Back to the Basics-Is Comfort Care the Same as Do Not Resuscitate? How Misinterpreting Code Status May Lead to Potential Patient Harm

Several research studies have shown that code status documentation is misinterpreted or incorrectly defined by a significant number of medical professionals. This misinterpretation among the medical team (i.e. equating Do Not Resuscitate (DNR) with comfort care measures only) may lead to false reporting, poor symptom management, and potentially adverse clinical outcomes. Most Hospice and Palliative Care providers are aware of these distinctions, however a shortage (and continued foreseen shortage) of Hospice and Palliative Care providers may mean these conversations and distinctions will fall to non-subspecialists, or providers of other medical specialties or degrees. The literature has demonstrated that these shortfalls and misinterpretations are present and constitute potential harm to our patients.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.

Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients

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.

The Do Not Resuscitate (DNR) order in the perioperative setting: practical considerations

PURPOSE OF REVIEW

Addressing patients' Do Not Resuscitate (DNR) status in the perioperative setting is important for shared patient decision-making. Although the inherently resuscitative nature of anesthesia and surgery may pose an ethical quandary for clinicians tasked with caring for the patient, anesthesiologist-led efforts need to evaluate all aspects of the DNR order and operative procedures.

RECENT FINDINGS

Approximately 15% of patients undergoing surgical procedures have a preexisting DNR order (Margolis et al., 1995) [1]. American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) do not support automatic reversal of the DNR order in the perioperative setting. Citing patient self-determination and autonomy, these societies advocate for a thoughtful discussion where a patient or legal designee may make an informed decision regarding resuscitation in the perioperative setting. Although studies have suggested increased perioperative mortality among patients with a preexisting DNR order, this data remains largely inconclusive.

SUMMARY

Efforts must be made to address the DNR order in the perioperative setting. The fundamental tenets of medical ethics, nonmaleficence, beneficence, and patient autonomy can help to guide this oftentimes challenging discussion.

Dementia and Early Do-Not-Resuscitate Orders Associated With Less Intensive of End-of-Life Care: A Retrospective Cohort Study

BACKGROUND

Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.

AIM

Examine the relationship between dementia, DNR timing, and end-of-life care intensity.

DESIGN

Observational cohort study.

SETTING/PARTICIPANTS

Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.

RESULTS

Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.

CONCLUSIONS

Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

Nurses' Opinions on Do-Not-Resuscitate Orders

The aim of this study was to determine nurses' opinions on Do Not Resuscitate (DNR) orders. This is a descriptive study. A total of 1250 nurses participated in this study. The mean age of participants was 34.5 ± 7.7 years; 92.6% were women; 56.4% had bachelor's degrees, and 28.8% were intensive care, oncology, or palliative care nurses. Most participants (94.3%) agreed that healthcare professionals involved in DNR decision-making processes should have ethical competence, while they were mostly undecided (43%) about the statement whether or not DNR should be legal. More than half the participants (60.2%) disagreed with the idea that DNR implementation causes an ethical dilemma. Participants' opinions on DNR decisions significantly differed according to the number of years of employment and unit of duty. The results showed that most of the nurses had positive attitudes towards DNR orders despite it being illegal. Future studies are needed to better understand family members' and decision makers' perceptions of DNR orders for patients.

Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study

BACKGROUND

US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied.

DESIGN AND METHODS

Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences.

RESULTS

The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories.

CONCLUSIONS

There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.

Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland

BACKGROUND

Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland.

METHODS

This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded.

RESULTS

There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001).

CONCLUSIONS

In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.

Early DNR Order and Long-Term Prognosis Among Patients Hospitalized for Acute Heart Failure: Single-Center Cohort Study in Japan

Purpose

An early do-not-resuscitate (DNR) order is classified as such when it occurs within 24 hours of admission. Early DNR has been previously associated with in-hospital mortality among acute heart failure (AHF) patients and one-year mortality among patients discharged from ICU. Here, we investigate whether early DNR is associated with long-term mortality in AHF Japanese patients, by performing a retrospective cohort study.

Patients and Methods

We retrospectively investigated all patients with AHF, admitted to our hospital between April 2013 and March 2015, and survived to discharge. We obtained data on demographics, comorbidities, laboratory and echocardiography results, social background, DNR status, and outcomes (one-year death). The association of early DNR with one-year death was analyzed by multivariate logistic regression analysis.

Results

Among 370 survive to discharge patients, 48 (12%) were lost to follow up. We analyzed 322 patients. The median age was 74 years, and 80 (25%) had an early DNR order. Patients with a DNR order were older and displayed more activities of daily living (ADL)-dependence. Early DNR was associated with higher one-year mortality.

Conclusion

Early DNR was associated with one-year mortality among AHF patients. Further studies are necessary to investigate unmeasured factors associated with a worse prognosis related to early DNR among AHF patients.

Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study

PURPOSE

The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients.

METHODS

This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system.

RESULTS

In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders.

CONCLUSIONS

Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.

Do-not-resuscitate orders in patients with community-acquired pneumonia: a retrospective study

Background

To investigate the use of do-not-resuscitate (DNR) orders in patients hospitalized with community-acquired pneumonia (CAP) and the association with mortality.

Methods

We assembled a cohort of 1317 adults hospitalized with radiographically confirmed CAP in three Danish hospitals. Patients were grouped into no DNR order, early DNR order (≤48 h after admission), and late DNR order (> 48 h after admission). We tested for associations between a DNR order and mortality using a cox proportional hazard model adjusted for patient and disease related factors.

Results

Among 1317 patients 177 (13%) patients received a DNR order: 107 (8%) early and 70 (5%) late, during admission. Patients with a DNR order were older (82 years vs. 70 years, p < 0.001), more frequently nursing home residents (41% vs. 6%, p < 0.001) and had more comorbidities (one or more comorbidities: 73% vs. 59%, p < 0.001). The 30-day mortality was 62% and 4% in patients with and without a DNR order, respectively. DNR orders were associated with increased risk of 30-day mortality after adjustment for age, nursing home residency and comorbidities. The association was modified by the CURB-65 score Hazard ratio (HR) 39.3 (95% CI 13.9–110.6), HR 24.0 (95% CI 11.9–48,3) and HR 9.4 (95% CI: 4.7–18.6) for CURB-65 score 0–1, 2 and 3–5, respectively.

Conclusion

In this representative Danish cohort, 13% of patients hospitalized with CAP received a DNR order. DNR orders were associated with higher mortality after adjustment for clinical risk factors. Thus, we encourage researcher to take DNR orders into account as potential confounder when reporting CAP associated mortality.

Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage

BACKGROUND

Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists.

METHODS

We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24 h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model.

RESULTS

A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant.

CONCLUSIONS

The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

Advance directives in the emergency department

Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.

Use of Combined Do-Not-Resuscitate/Do-Not Intubate Orders Without Documentation of Intubation Preferences: A Retrospective Observational Study at an Academic Level 1 Trauma Center Code Status and Intubation Preferences

BACKGROUND

Combining orders for do-not-resuscitate (DNR) for cardiac arrest with do-not-intubate (DNI) orders into a DNR/DNI code status is not evidence-based practice and may violate patient autonomy and informed consent when providers discuss intubation only in the context of CPR.

RESEARCH QUESTION

How often do providers refer to patients with a DNR order as "DNR/DNI" without documentation of refusal of intubation for non-arrest situations?

METHODS

Retrospective observational study of adults (18 years of age or older) hospitalized in a Level 1 trauma/academic hospital between July 2017 and June 2018 inclusive with DNR orders placed during hospitalization.

RESULTS

Of 422 hospitalized adults with DNR orders, 261 (61.9%) had code status written in progress notes as DNR/DNI. Providers' use of the term DNR/DNI in progress notes was significantly (OR, 2.21; 99% CI, 1.12-4.37) more common on medical hospital services (hospitalist, family medicine, internal medicine) than on nonmedical ward services (medical/surgical ICUs, surgery, psychiatry, neurology services). Of 261 "DNR/DNI" patients, providers did not document informed refusal of intubation for nonarrest situations for 68 (26.0%) of patients. By comparison, of 161 patients for whom providers documented code status in progress notes as DNR alone, 69 (42.9%) did have documentation of refusal of intubation for nonarrest events. Therefore, if a DNR/DNI code status was used in a nonarrest emergency to determine whether to intubate a patient, 68 (16.1%) of 422 patients could inappropriately be denied intubation without informed refusal (or despite their informed acceptance), and 69 (16.4%) could inappropriately be intubated despite their documented refusal of intubation.

CONCLUSIONS

Conflation of DNR and DNI into DNR/DNI does not reliably distinguish patients who refuse or accept intubation for indications other than cardiac arrest, and thus may inappropriately deny desired intubation for those who would accept it, and inappropriately impose intubation on patients who would not.

Pediatricians' Perceptions Toward Do Not Resuscitate: A Survey in Saudi Arabia and Literature Review

OBJECTIVE

To explore the pediatricians' attitudes and perceptions toward do-not-resuscitate (DNR) orders in a specific region of the world not fully explored before.

METHODS

A cross-sectional study was conducted between March 4 and May 30, 2018. Pediatricians from three public hospitals in the city of Riyadh were asked to respond to a questionnaire consisting of 22 questions designed to meet the objectives of our study.

RESULTS

A total of 203 pediatricians (51.2% female) completed the questionnaire, both junior pediatricians (JPs) and senior pediatricians (SPs). A majority (58.9% of JPs and 61.4% of SPs) thought patients have the right to demand intensive care, despite their terminal illness. Half the participants in both groups thought that DNR is a physician's decision. Only 9.3% of JPs and 12.5% of SPs felt comfortable discussing DNR with patients/families. Medical school was also a source of knowledge on DNR issues, mainly for JPs (40.2% of JPs vs 20.8% of SPs, P=0.005). Half the participants felt that DNR is consistent with Islamic beliefs, while 57.9% of JPs vs 41.7% of SPs felt they are legally protected. Hospital policy was clear to 48.6% of JPs vs 66.7% of SPs, while procedure was clear to 35.5% of JPs vs 49% of SPs.

CONCLUSION

Several factors are present that may hinder DNR implementation, such as doubts concerning being legally protected, doubts concerning consistency with Islamic sharia, unclear policies and procedures, and lack of training and orientation on DNR issues. Policies may need to include patients as decision-makers.

Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents’ Decision Making

BACKGROUND

Research has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care.

OBJECTIVES

The purpose of this study was to assess the influence of code status on emergency residents' decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts.

METHODS

We conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents.

RESULTS

Three hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p < 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p < 0.001), offer dialysis (79.3% vs. 98.0%, p < 0.001), and surgical consultation (78.7% vs. 94.2%, p < 0.001).

CONCLUSIONS

In a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.

Are physicians on the same page about do-not-resuscitate? To examine individual physicians' influence on do-not-resuscitate decision-making: a retrospective and observational study

Background

Individual physicians and physician-associated factors may influence patients’/surrogates’ autonomous decision-making, thus influencing the practice of do-not-resuscitate (DNR) orders. The objective of this study was to examine the influence of individual attending physicians on signing a DNR order.

Methods

This study was conducted in closed model, surgical intensive care units in a university-affiliated teaching hospital located in Northern Taiwan. The medical records of patients, admitted to the surgical intensive care units for the first time between June 1, 2011 and December 31, 2013 were reviewed and data collected. We used Kaplan–Meier survival curves with log-rank test and multivariate Cox proportional hazards models to compare the time from surgical intensive care unit admission to do-not-resuscitate orders written for patients for each individual physician. The outcome variable was the time from surgical ICU admission to signing a DNR order.

Results

We found that each individual attending physician’s likelihood of signing do-not-resuscitate orders for their patients was significantly different from each other. Some attending physicians were more likely to write do-not-resuscitate orders for their patients, and other attending physicians were less likely to do so.

Conclusion

Our study reported that individual attending physicians had influence on patients’/surrogates’ do-not-resuscitate decision-making. Future studies may be focused on examining the reasons associated with the difference of each individual physician in the likelihood of signing a do-not-resuscitate order.

The impact of language on the interpretation of resuscitation clinical care plans by doctors. A mixed methods study

Introduction

Resuscitation clinical care plans (resuscitation plans) are gradually replacing ‘Not for Cardiopulmonary Resuscitation’ orders in the hospital setting. The 7-Step Pathway Resuscitation Plan and Alert form (7-Step form) is one example of a resuscitation plan. Treatment recommendations in resuscitation plans currently lack standardised language, creating potential for misinterpretation and patient harm.

Aims

To explore how terminology used in resuscitation plans is interpreted and applied by clinicians.

Method

A mixed methods study surveyed 50 general medical doctors, who were required to interpret and apply a 7-Step form in three case vignettes and define seven key terms. Statistical analysis on multiple choice and thematic analysis on free-text responses was performed.

Results

Terminology was inconsistently interpreted and inconsistently applied, resulting in clinically significant differences in treatment choices. Three key themes influenced the application of a resuscitation plan: in-depth discussion, precise documentation and personal experience of the bedside deciding doctor.

Discussion

This study highlights persistent communication deficiencies in resuscitation plan documentation and how this may adversely affect patient care; findings unlikely to be unique to Australia or South Australia.

Conclusion

Removing ambiguity by standardising and defining the terminology in resuscitation plans will improve bedside decision-making, while also supporting the rights of the patient to receive appropriate and desired care.

Developing an intervention around referral and admissions to intensive care: a mixed-methods study

Background

Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

Objectives

To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

Methods

A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.

Results

Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

Limitations

Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.

Conclusions

Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.

Future work

Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.

Study registration

The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults

CONTEXT

Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values.

OBJECTIVES

To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent.

METHODS

Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states.

RESULTS

Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804).

CONCLUSION

Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.

Doctors' attitudes regarding not for resuscitation orders

Objectives The aims of the present study were to investigate doctors' attitudes regarding the discussion and writing of not for resuscitation (NFR) orders and to identify potential barriers to the completion of these orders. Methods A questionnaire-based convenience study was undertaken at a tertiary hospital. Likert scales and open-ended questions were directed to issues surrounding the discussion, timing, understanding and writing of NFR orders, including legal and personal considerations. Results Doctors thought the presence of an NFR order both should and does alter care delivered by nursing staff, particularly delivery of pain relief, nursing observations and contacting the medical emergency team. Eighty-five per cent of doctors believed they needed somebody else's consent to write an NFR order (seeking of consent is not a requirement in most Australian jurisdictions). Conclusion There are complex barriers to the writing and implementation of NFR orders, including doctors' knowledge around the need for consent when cardiopulmonary resuscitation is likely to be futile or excessively burdensome. Doctors also believed that NFR orders result in changes to goals-of-care, suggesting a confounding of NFR orders with palliative care. Furthermore, doctors are willing to write NFR orders where there is clear medical indication and the patient is imminently dying, but are otherwise reliant on patients and family to initiate discussion. What is known about the topic? Hospitalised elderly patients, in the absence of an NFR order, are known to have poor survival and outcomes following resuscitation. Further, Australian data on the prevalence of NFR forms show that only a minority of older in-patients have a written NFR order in their history. In Australian hospitals, NFR orders are completed by doctors. What does this paper add? To our knowledge, the present study is the first in Australia to qualitatively analyse doctors' reasons to writing NFR orders. The open-text nature of this questioning has been important in eliciting doctors' responses without hypothesis guessing bias. Further, we add to the literature on the breadth of considerations doctors may encounter with regard to NFR orders. What are the implications for practitioners? The findings indicate the issues impeding decision making around cardiopulmonary resuscitation relate to poor knowledge of the law, particularly around the issue of consent and confounding NFR orders with provision of palliative care. Such barriers to the completion of NFR orders expose elderly in-patients to futile and burdensome resuscitation events. The findings suggest consideration be given to education and training materials to inform doctors about jurisdictional law regarding resuscitation documentation, support decision making around cardiopulmonary resuscitation and promote goals-of-care discussions on admission.

Perception of palliative medicine by health care professionals at a teaching community hospital: what is the key to a "palliative attitude"?

Background: With growing expense in chronic illness and end-of-life (EOL) care, population-based interventions are needed to reduce the health care cost and improve patients' quality of life. The authors believe that promotion of palliative medicine is one such intervention and this promotion depends on the acceptance of palliative medicine concepts by health care professionals. Aims of the studies: Perception of palliative medicine in chronic illness and in EOL care by health care professionals was learned in two studies carried out at a teaching community hospital 14 years apart. Participants and methods: Voluntary and anonymous surveys were randomly distributed among physicians, nurses, and social workers/case managers. Participants in the two studies presented two different groups of health care providers. Results of the studies: Results of the two studies were essentially similar. On most of the issues, respondents' perceptions were consistent with palliative medicine concepts and confidence in palliation grew over the 14-year period. The authors call this approach a "palliative attitude." Physicians with greater experience performed better in care planning. Younger physicians were more perceptive to withdrawal of care in futile cases. Participants' religion had no influence on perception of palliative medicine. Attendance of educational activities did not influence attitudes of health care professionals. Health care providers who favored involvement of palliative care teams in patients' management were better in care planning, interpretation of the DNR consent, use of opioids at the EOL, use of intensive care, and evaluation of the disease trajectory. Conclusion: The authors conclude that direct interaction between palliative and interdisciplinary teams in clinical practice is the key factor in the education of health care professionals, in the development of a "palliative attitude," and in the promotion of palliative medicine.

Examining Age Inequalities in Operationalized Components of Advance Care Planning: Truncation of the ACP Process With Age

CONTEXT

Opportunities for patients to receive unnecessary, costly, and potentially harmful care near the end of life abound. Advance care planning (ACP) can help to make this vulnerable period better for patients, caregivers, and providers.

OBJECTIVE

The objective of this study was to determine whether older age predicted the presence of certain forms of retrievable ACP documentation in the electronic health record (EHR) in a large sample of hospice-referred patients.

METHODS

This was a retrospective analysis of medical-record data on 3595 patients referred to hospice between January 1, 2013 and December 31, 2015. EHR documentation of an ACP note in the problem list, presence of a scanned advance directive, and the presence of a verified do-not-resuscitate order were the outcome measures. Logistic regression was used to assess the effect of age, education, race, gender, cancer diagnosis, dementia diagnosis, palliative encounter, and death on the outcome variables.

RESULTS

Our results suggest that when we control for prognosis, patients over age 70 years may experience gaps in ACP communication. We found that as patients age, the odds of having documentation of a conversation (odds ratio [OR] = 0.56; P < 0.001) or scanned advance directive decreased (OR = 0.63; P < 0.001), while the odds of having a verified do-not-resuscitate order increased (OR = 1.42; P < 0.001).

CONCLUSION

The results of this study may imply some degree of unilateral and physician-driven decision making for end-of-life care among older adults. Collaborative efforts between an interdisciplinary medical team should focus on developing policies to address this potential disparity between younger and older adults at the end of life.

Effect of a do-not-resuscitate order on the quality of care in acute heart failure patients: a single-center cohort study

Background

A do-not-resuscitate (DNR) order is reportedly associated with a decrease in performance measures, but it should not be applied to noncardiopulmonary resuscitation procedures. Good performance measures are associated with improvement in heart failure outcomes.

Aim

To analyze the influence of DNR order on performance measures of heart failure at our hospital, where lectures on DNR order are held every 3 months.

Design

Retrospective cohort study.

Methods

The medical report of patients with acute heart failure who were admitted between April 2013 and March 2015 were retrospectively analyzed. We collected demographic data, information on the presence or absence of DNR order within 24 hours of admission, and inhospital mortality. Performance measures of heart failure, including assessment of cardiac function and discharge prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and beta-blocker for left ventricular systolic dysfunction and anticoagulant for atrial fibrillation, were collected and compared between groups with and without DNR orders.

Results

In 394 total patients and 183 patients with left ventricular systolic dysfunction, 114 (30%) and 44 (24%) patients, respectively, had a DNR order. Patients with a DNR order had higher inhospital mortality. There were no significant differences between the two groups in terms of the four quality measures (left ventricular function assessment, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, and anticoagulant).

Conclusion

DNR orders did not affect performance measures, but they were associated with higher inhospital mortality among acute heart failure patients.

Factors associated with combined do-not-resuscitate and do-not-intubate orders: A retrospective chart review at an urban tertiary care center

BACKGROUND

In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders.

OBJECTIVE

To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders.

DESIGN

Retrospective chart review.

SETTING/SUBJECTS

Patients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period.

MEASUREMENTS

Logistic regression was used to identify demographic and medical data associated with code status.

RESULTS

Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00).

CONCLUSIONS

Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.

Out-of-hospital cardiac arrest with Do-Not-Resuscitate orders signed in hospital: Who are the survivors?

BACKGROUND

Signing Do-Not-Resuscitate orders is an important element contributing to a worse prognosis for out-of-hospital cardiac arrest (OHCA). However, our data showed that some of those OHCA patients with Do-Not-Resuscitate orders signed in hospital survived to hospital discharge, and even recovered with favorable neurological function. In this study, we described their clinical features and identified those factors that were associated with better outcomes.

METHODS

A retrospective, observational analysis was performed on all adult non-traumatic OHCA who were enrolled in the Resuscitation Outcomes Consortium (ROC) PRIMED study but signed Do-Not-Resuscitate orders in hospital after admission. We reported their demographics, characteristics, interventions and outcomes of all enrolled cases. Patients surviving and not surviving to hospital discharge, as well as those who did and did not obtain favorable neurological recovery, were compared. Logistic regression models assessed those factors which might be prognostic to survival and favorable neurological outcomes at discharge.

RESULTS

Of 2289 admitted patients with Do-Not-Resuscitate order signed in hospital, 132(5.8%) survived to hospital discharge and 28(1.2%) achieved favorable neurological recovery. Those factors, including witnessed arrest, prehospital shock delivered, Return of Spontaneous Circulation (ROSC) obtained in the field, cardiovascular interventions or procedures applied, and no prehospital adrenaline administered, were independently associated with better outcomes.

CONCLUSIONS

We suggest that some factors should be taken into considerations before Do-Not-Resuscitate decisions are made in hospital for those admitted OHCA patients.