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Doody O, Davidson H, Lombard J. Do not attempt cardiopulmonary resuscitation decision-making process: scoping review. BMJ Support Palliat Care 2024:spcare-2023-004573. [PMID: 38519106 DOI: 10.1136/spcare-2023-004573] [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: 08/25/2023] [Accepted: 02/23/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVES To conduct a scoping review to explore the evidence of the process of do not attempt cardiopulmonary resuscitation (DNACPR) decision-making. METHODS We conducted a systematic search and review of articles from 1 January 2013 to 6 April 2023 within eight databases. Through multi-disciplinary discussions and content analytical techniques, data were mapped onto a conceptual framework to report the data. RESULTS Search results (n=66 207) were screened by paired reviewers and 58 papers were included in the review. Data were mapped onto concepts/conceptual framework to identify timing of decision-making, evidence of involvement, evidence of discussion, evidence of decision documented, communication and adherence to decision and recommendations from the literature. CONCLUSION The findings provide insights into the barriers and facilitators to DNACPR decision-making, processes and implementation. Barriers arising in DNACPR decision-making related to timing, patient/family input, poor communication, conflicts and ethical uncertainty. Facilitators included ongoing conversation, time to discuss, documentation, flexibility in recording, good communication and a DNACPR policy. Challenges will persist unless substantial changes are made to support and promote examples of good practice. Overall, the review underlined the complexity of DNACPR decision-making and how it is a process shaped by multiple factors including law and policy, resource investment, healthcare professionals, those close to the patient and of central importance, the patient.
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Affiliation(s)
- Owen Doody
- Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Hope Davidson
- School of Law, University of Limerick, Limerick, Ireland
| | - John Lombard
- School of Law, University of Limerick, Limerick, Ireland
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2
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Sheehan R, Ding J, White A, Magill N, Chauhan U, Marshall-Tate K, Strydom A. Specialist intellectual disability liaison nurses in general hospitals in England: cohort study using a large mortality dataset. BMJ Open 2024; 14:e077124. [PMID: 39122397 DOI: 10.1136/bmjopen-2023-077124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024] Open
Abstract
OBJECTIVE Intellectual disability liaison nurses in general hospitals could enhance access to high-quality, adapted healthcare and improve outcomes. We aimed to explore associations between the input of intellectual disability liaison nurses and the quality of care in people with intellectual disability who are admitted to hospital. DESIGN Retrospective analysis of a national dataset of mortality reviews. SETTING General hospitals in England. PARTICIPANTS 4742 adults with intellectual disability who died in hospital between 2016 and 2021 and whose deaths were reviewed as part of the Learning from Lives and Deaths mortality review programme. OUTCOME MEASURES We used logistic regression to compare the sociodemographic and clinical characteristics of those who did, and did not, receive input from an intellectual disability liaison nurse. We explored associations between liaison nurse input, care processes and overall quality of care. RESULTS One-third of people with intellectual disability who died in hospital in England between 2016 and 2021 had input from an intellectual disability liaison nurse. Intellectual disability liaison nurse input was not evenly distributed across England and was more common in those who died of cancer. Having an intellectual disability liaison nurse involved in an individual's care was associated with increased likelihood of reasonable adjustments being made to care (adjusted OR (aOR) 1.95, 95% CI 1.63 to 2.32) and of best practice being identified (aOR 1.37, 95% CI 1.17 to 1.60) but was not associated with a rating of overall quality of care received (aOR 0.94, 95% CI 0.78 to 1.12). CONCLUSIONS Intellectual disability liaison nurses see only a minority of people with intellectual disability who are admitted to hospital in England. Increasing the availability of intellectual disability liaison nurses could improve care for this disadvantaged group.
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Affiliation(s)
- Rory Sheehan
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Oxleas NHS Foundation Trust, Dartford, UK
| | - Jonathon Ding
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Adam White
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nicholas Magill
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Karina Marshall-Tate
- South London and Maudsley NHS Foundation Trust, London, UK
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - André Strydom
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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3
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Underwood M, Noufaily A, Blanchard H, Dale J, Harlock J, Gill P, Griffiths F, Spencer R, Slowther AM. GPs' views on emergency care treatment plans: an online survey. BJGP Open 2024; 8:BJGPO.2023.0192. [PMID: 38191186 PMCID: PMC11300997 DOI: 10.3399/bjgpo.2023.0192] [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: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 01/10/2024] Open
Abstract
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.
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Affiliation(s)
- Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | | | | | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paramjit Gill
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Spencer
- Warwick Medical School, University of Warwick, Coventry, UK
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4
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King O, Collman E, Evans A, Richards J, Hughes E, Acquah L, Parsons H, Morrison J. Improving the visibility and communication of treatment escalation plans in Somerset NHS foundation trust. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2022; 33:S69-S72. [PMID: 35871371 PMCID: PMC9844060 DOI: 10.3233/jrs-227027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Advance care treatment escalation plans (TEPs) are often lost between healthcare settings, leading to duplication of work and loss of patient autonomy. OBJECTIVE This quality improvement project reviewed the usage of TEP forms and aimed to improve completeness of documentation and visibility between admissions. METHODS Over four months we monitored TEP form documentation using a standardised data extraction form. This examined section completion, seniority of documenting clinician and transfer of forms to our hospital electronic patient record (EPRO). We added reminders to computer monitors on wards to improve EPRO upload. RESULTS Initial data demonstrated that 95% of patients (n = 230) had a TEP, with 99% of TEPs recording resuscitation status. However, other sections were not well documented (patient capacity 57% completion and personal priorities 45% completion, respectively). Only 11.9% of TEPs documented consultant involvement. Furthermore, only 44% of TEPs with a do not attempt resuscitation (DNACPR) decision were uploaded. Following this, we added reminders to computer monitors explaining how to upload TEP decisions to EPRO, which increased EPRO uploads to 74%. CONCLUSION Communication of TEPs needs improving across healthcare settings. This project showed that the use of a physical reminder can greatly improve communication of treatment escalation decisions. Furthermore, this intervention has inspired future projects aiming at making communication more sustainable through the use of discharge summaries.
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Affiliation(s)
- Oliver King
- Salisbury NHS Foundation Trust, Salisbury, UK, Address for correspondence: Dr Oliver King, Salisbury NHS Foundation Trust, Salisbury, UK. E-mail:
| | | | - Alice Evans
- Wyong Hospital, Hamlyn Terrace, NSW, Australia
| | | | - Elin Hughes
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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5
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Clements H, El Boghdady M, Alijani A. Acute surgical admissions at the end of life-an analysis of non-operative hospital deaths. Surgeon 2021; 20:351-355. [PMID: 34840066 DOI: 10.1016/j.surge.2021.09.003] [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: 06/05/2021] [Accepted: 09/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission. METHODS This single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis. RESULTS A total of 72 patients were included in this study, of which 68.1% died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p < 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death. CONCLUSION Frailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.
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Affiliation(s)
- Hollie Clements
- Department of General Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Michael El Boghdady
- Department of General Surgery, Kingston Hospital NHS Foundation Trust, London, UK; St George's University, London, UK.
| | - Afshin Alijani
- Department of General Surgery, Ninewells Hospital and Medical School, Dundee, UK
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6
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Eli K, Hawkes CA, Fritz Z, Griffin J, Huxley CJ, Perkins GD, Wilkinson A, Griffiths F, Slowther AM. Assessing the quality of ReSPECT documentation using an accountability for reasonableness framework. Resusc Plus 2021; 7:100145. [PMID: 34382025 PMCID: PMC8340300 DOI: 10.1016/j.resplu.2021.100145] [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: 12/18/2020] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, which supports the ReSPECT process, is designed to prompt clinicians to discuss wider emergency treatment options with patients and to structure the documentation of decision-making for greater transparency. Methods Following an accountability for reasonableness framework (AFR), we analysed 141 completed ReSPECT forms (versions 1.0 and 2.0), collected from six National Health Service (NHS) hospitals in England during the early adoption of ReSPECT. Structured through an evaluation tool developed for this study, the analysis assessed the extent to which the records reflected consistency, transparency, and ethical justification of decision-making. Results Recommendations relating to CPR were consistently recorded on all forms and were contextualised within other treatment recommendations in most forms. The level of detail provided about treatment recommendations varied widely and reasons for treatment recommendations were rarely documented. Patient capacity, patient priorities and preferences, and the involvement of patients/relatives in ReSPECT conversations were recorded in some, but not all, forms. Clinicians almost never documented their weighing of potential burdens and benefits of treatments on the ReSPECT forms. Conclusion In most ReSPECT forms, CPR recommendations were captured alongside other treatment recommendations. However, ReSPECT form design and associated training should be modified to address inconsistencies in form completion. These modifications should emphasise the recording of patient values and preferences, assessment of patient capacity, and clinical reasoning processes, thereby putting patient/family involvement at the core of good clinical practice. Version 3.0 of ReSPECT responds to these issues.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, UK
| | | | - Zoë Fritz
- Cambridge University Hospitals NHS Foundation Trust, UK
| | | | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, UK.,University Hospitals Birmingham NHS Foundation Trust, UK
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7
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Huxley CJ, Eli K, Hawkes CA, Perkins GD, George R, Griffiths F, Slowther AM. General practitioners' experiences of emergency care and treatment planning in England: a focus group study. BMC FAMILY PRACTICE 2021; 22:128. [PMID: 34167478 PMCID: PMC8224258 DOI: 10.1186/s12875-021-01486-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 06/07/2021] [Indexed: 11/21/2022]
Abstract
Background Emergency Care and Treatment Plans are recommended for all primary care patients in the United Kingdom who are expected to experience deterioration of their health. The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was developed to integrate resuscitation decisions with discussions about wider goals of care. It summarises treatment recommendations discussed and agreed between patients and their clinicians for a future emergency situation and was designed to meet the needs of different care settings. Our aim is to explore GPs’ experiences of using ReSPECT and how it transfers across the primary care and secondary care interface. Methods We conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. Participants were asked about their experience of ReSPECT, how they initiate ReSPECT-type conversations, and their experiences of ReSPECT-type recommendations being communicated across primary and secondary care. Focus groups were transcribed and analysed using Thematic Analysis. Results GPs conceptualise ReSPECT as an end of life planning document, which is best completed in primary care. As an end of life care document, completing ReSPECT is an emotional process and conversations are shaped by what a ‘good death’ is thought to be. ReSPECT recommendations are not always communicated or transferable across care settings. A focus on the patient’s preferences around death, and GPs’ lack of specialist knowledge, could be a barrier to completion of ReSPECT that is transferable to acute settings. Conclusion Conceptualising ReSPECT as an end of life care document suggests a difference in how general practitioners understand ReSPECT from its designers. This impacts on the transferability of ReSPECT recommendations to the hospital setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01486-w.
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Affiliation(s)
- Caroline J Huxley
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Karin Eli
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Claire A Hawkes
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Rob George
- St Christopher's Hospice, 51-59 Lawrie Park Road, London, SE26 6DZ, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK.
| | - Anne-Marie Slowther
- Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
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8
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Batten JN, Blythe JA, Wieten S, Cotler MP, Kayser JB, Porter-Williamson K, Harman S, Dzeng E, Magnus D. Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study. BMJ Qual Saf 2020; 30:668-677. [PMID: 33082165 DOI: 10.1136/bmjqs-2020-011222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/01/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Jason N Batten
- Department of Medicine, Stanford University, Stanford, California, USA .,Department of Anesthesia, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Jacob A Blythe
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah Wieten
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Piven Cotler
- Department of Health Sciences, California State University Northridge, Northridge, California, USA
| | - Joshua B Kayser
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Karin Porter-Williamson
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Stephanie Harman
- Department of Medicine, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
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McLachlan S, Kyrimi E, Dube K, Hitman G, Simmonds J, Fenton N. Towards standardisation of evidence-based clinical care process specifications. Health Informatics J 2020; 26:2512-2537. [DOI: 10.1177/1460458220906069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.
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Affiliation(s)
- Scott McLachlan
- Health informatics and Knowledge Engineering Research Group (HiKER), New Zealand; Queen Mary University of London, UK
| | | | - Kudakwashe Dube
- Health informatics and Knowledge Engineering Research Group (HiKER), New Zealand; Massey University, New Zealand
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10
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Eli K, Ochieng C, Hawkes C, Perkins GD, Couper K, Griffiths F, Slowther AM. Secondary care consultant clinicians' experiences of conducting emergency care and treatment planning conversations in England: an interview-based analysis. BMJ Open 2020; 10:e031633. [PMID: 31964663 PMCID: PMC7044868 DOI: 10.1136/bmjopen-2019-031633] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine secondary care consultant clinicians' experiences of conducting conversations about treatment escalation with patients and their relatives, using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process. DESIGN Semi-structured interviews following ward round observations. SETTING Two National Health Service hospitals in England. PARTICIPANTS Fifteen medical and surgical consultants from 10 specialties, observed in 14 wards. ANALYSIS Interview transcripts were analysed using thematic analysis. RESULTS Three themes were developed: (1) determining when and with whom to conduct a ReSPECT conversation; (2) framing the ReSPECT conversation to manage emotions and relationships and (3) reaching ReSPECT decisions. The results showed that when timing ReSPECT conversations, consultant clinicians rely on their predictions of a patient's short-term prognosis; when framing ReSPECT conversations, consultant clinicians seek to minimise distress and maximise rapport and when involving a patient or a patient's relatives in decision-making discussions, consultant clinicians are guided by their level of certainty about the patient's illness trajectory. CONCLUSIONS The management of uncertainty about prognoses and about patients' emotional reactions is central to secondary care consultant clinicians' experiences of timing and conducting ReSPECT conversations.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Claire Hawkes
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith Couper
- Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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11
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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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12
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Variation in do not attempt cardiopulmonary resuscitation orders and emergency care and treatment plan use in English acute hospitals: A national survey. Resuscitation 2018. [DOI: 10.1016/j.resuscitation.2018.07.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Kalu QN, Oku OO, Ilori IAU. Establishing Cardiopulmonary Resuscitation Services in Sub-Saharan Africa: A Survey of Suggestions Made by Health Care Workers in Cross River State, Nigeria. Open Access Maced J Med Sci 2018; 6:944-948. [PMID: 29875877 PMCID: PMC5985863 DOI: 10.3889/oamjms.2018.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Rising trend in Non-Communicable Diseases (NCDs) in developing countries often result in sudden death, which are largely preventable through effective cardiopulmonary resuscitation (CPR). Most communities in Sub-Saharan Africa, however, lack access to CPR services, due to a deficiency in requirements for the establishment of such services. These requirements can be grouped into a triad of awareness, infrastructure and capacity building. AIM This study was aimed at assessing the perceived need and recommendations for improvement in CPR services in Cross River State. METHODS Proportionate sampling was used to recruit healthcare workers in this cross-sectional study. Data was obtained using semi-structured open-ended questionnaire consisting of recommendations for improving CPR services. Responses were coded and grouped into three essential areas. Data were entered and analysed using SPSS version 20.0. RESULT Two hundred and twenty-nine (229) questionnaires were completed; mean age of respondents was 42.1 ± 11.2 years. The commonest cadre of healthcare worker was nurses (135, 59.0%). One, two, and three areas of suggestions were made by 55.5%, 37.1%, and 7.4% of respondents, respectively. Suggestions included training of health care workers on CPR (111, 48.5%) and provision of resuscitation equipment (95, 41.5%). Sixty-five respondents (29.3%) recommended creating awareness and means of contact, while some respondents recommended capacity building (132, 57.6%) and resuscitation infrastructure set-up (149, 65.1%). CONCLUSION Healthcare workers perceive an urgent need for the establishment of CPR services in our health facilities and communities. There is need to address the triad of awareness, infrastructure and capacity building for the establishment of CPR services peculiar to Sub-Saharan Africa.
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Affiliation(s)
| | - Oboko Oboko Oku
- Department of Anaesthesiology, University of Calabar, Calabar, Nigeria
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Aggarwal AR, Khan I. Medical students' experiences of resuscitation and discussions surrounding resuscitation status. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2018; 9:31-37. [PMID: 29391840 PMCID: PMC5768191 DOI: 10.2147/amep.s141436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES In the UK, cardiopulmonary resuscitation (CPR) should be undertaken in the event of cardiac arrest unless a patient has a "Do Not Attempt CPR" document. Doctors have a legal duty to discuss CPR with patients or inform them that CPR would be futile. In this study, final-year medical students were interviewed about their experiences of resuscitation on the wards and of observing conversations about resuscitation status to explore whether they would be equipped to have an informed discussion about resuscitation in the future. METHODS Twenty final-year medical students from two medical schools were interviewed about their experiences on the wards. Interviews were transcribed verbatim, and thematic analysis was undertaken. RESULTS Students who had witnessed CPR on the wards found that aspects of it were distressing. A significant minority had never seen resuscitation status being discussed with a patient. No students reported seeing a difficult conversation. Half of the students interviewed reported being turned away from difficult conversations by clinicians. Only two of the twenty students would feel comfortable raising the issue of resuscitation with a patient. CONCLUSION It is vital that doctors are comfortable talking to patients about resuscitation. Given the increasing importance of this aspect of communication, it should be considered for inclusion in the formal communication skills teaching during medical school.
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Affiliation(s)
- Asha R Aggarwal
- Department of Medical Education, Northampton General Hospital, Northampton, UK
| | - Iqbal Khan
- Department of Medical Education, Northampton General Hospital, Northampton, UK
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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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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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Ewings R. Limitations of care and do not resuscitate orders: A patient's/relative's perspective. Resuscitation 2016; 98:A5-6. [DOI: 10.1016/j.resuscitation.2015.09.393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 11/29/2022]
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Piscator E, Hedberg P, Göransson K, Djärv T. Survival after in-hospital cardiac arrest is highly associated with the Age-combined Charlson Co-morbidity Index in a cohort study from a two-site Swedish University hospital. Resuscitation 2015; 99:79-83. [PMID: 26708451 DOI: 10.1016/j.resuscitation.2015.11.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/29/2015] [Accepted: 11/25/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) has a poor prognosis and clinicians often write "Do-Not-Attempt-Resuscitation" (DNAR) orders based on co-morbidities. AIM To assess the impact of the Age-combined Charlson Co-morbidity Index (ACCI) on 30-days survival after IHCA. MATERIAL AND METHODS All patients suffering IHCA at Karolinska University Hospital between 1st January and 31st December 2014 were included. Data regarding patient characteristics, co-morbidities and survival were drawn from the electronic patient records. Co-morbidities were assessed prior to the IHCA as ICD-10 codes according to the ACCI. Differences in survival were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI) between patients with an ACCI of 0-4 points versus those with 5-7 points, as well as those with ≥8 points. Adjustments included hospital site, heart rhythm, ECG surveillance, witnessed status and place of IHCA. RESULTS In all, 174 patients suffered IHCA, of whom 41 (24%) survived at least 30 days. Patients with an ACCI of 5-7 points had a minor chance and those with an ACCI of ≥8 points had a minimal chance of surviving IHCA compared to those with an ACCI of 0-4 points (adjusted OR 0.10, 95% CI 0.04-0.26 and OR 0.04, 95% CI 0.03-0.42, respectively). CONCLUSION Patients with a moderate or severe burden of ACCI have a minor chance of surviving an IHCA. This information could be used as part of the decision tools during ongoing CPR, and could be an aid for clinicians in planning care and discussing DNAR orders.
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Affiliation(s)
- Eva Piscator
- Department of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden; Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Pontus Hedberg
- Department of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Katarina Göransson
- Department of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden; Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Therese Djärv
- Department of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden; Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
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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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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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