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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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Hyson L, Fritz Z. Advance and future care planning. BMJ 2024; 384:e074797. [PMID: 38438191 DOI: 10.1136/bmj-2023-074797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Lara Hyson
- Bart's Health NHS Trust, London E1 1BB, UK
| | - Zoë Fritz
- Cambridge University Hospitals NHS Foundation Trust; THIS (The Healthcare Improvement Studies) Institute University of Cambridge, Cambridge, UK
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3
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Nallamothu BK, Greif R, Anderson T, Atiq H, Couto TB, Considine J, De Caen AR, Djärv T, Doll A, Douma MJ, Edelson DP, Xu F, Finn JC, Firestone G, Girotra S, Lauridsen KG, Leong CKL, Lim SH, Morley PT, Morrison LJ, Moskowitz A, Mullasari Sankardas A, Mohamed MTM, Myburgh MC, Nadkarni VM, Neumar RW, Nolan JP, Athieno Odakha J, Olasveengen TM, Orosz J, Perkins GD, Previdi JK, Vaillancourt C, Montgomery WH, Sasson C, Chan PS. Ten Steps Toward Improving In-Hospital Cardiac Arrest Quality of Care and Outcomes. Circ Cardiovasc Qual Outcomes 2023; 16:e010491. [PMID: 37947100 PMCID: PMC10659256 DOI: 10.1161/circoutcomes.123.010491] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Affiliation(s)
| | - Robert Greif
- Department of Anesthesiology and Pain Medicine, University of Bern, Switzerland (R.G.)
| | - Theresa Anderson
- Department of Internal Medicine, University of Michigan Medical, Ann Arbor (B.K.N., T.A.)
| | - Huba Atiq
- Centre of Excellence for Trauma and Emergencies, Aga Khan University Hospital, Pakistan (H.A.)
| | | | | | - Allan R. De Caen
- Division of Pediatric Critical Care, Stollery Children’s Hospital, Edmonton, Canada (A.R.D.C.)
| | - Therese Djärv
- Department of Medicine, Karolinska Institute, Stockholm, Sweden (T.D.)
| | - Ann Doll
- Global Resuscitation Alliance, Seattle, WA (A.D.)
| | - Matthew J. Douma
- Department of Critical Care Medicine, University of Alberta, Canada (M.J.D.)
| | - Dana P. Edelson
- Department of Medicine, University of Chicago Medicine, IL (D.P.E.)
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, China (F.X.)
| | - Judith C. Finn
- School of Nursing, Curtin University, Perth, Australia (J.F.)
| | - Grace Firestone
- Department of Family Medicine, University of California Los Angeles Health, Santa Monica (G.F.)
| | - Saket Girotra
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas (S.G.)
| | | | - Carrie Kah-Lai Leong
- Department of Emergency Medicine, Singapore General Hospital (C.K.-L.L., S.H.L.)
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital (C.K.-L.L., S.H.L.)
| | - Peter T. Morley
- Department of Intensive Care, The University of Melbourne, Australia (P.T.M.)
| | - Laurie J. Morrison
- Division of Emergency Medicine, University of Toronto, Ontario, Canada (L.J.M.)
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, The Bronx, NY (A.M.)
| | | | | | | | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care, Childrens Hospital of Philadelphia, PA (V.N.)
| | - Robert W. Neumar
- Department of Emergency Medicine, University of Michigan, Ann Arbor (R.W.N.)
| | - Jerry P. Nolan
- University of Warwick, Coventry, United Kingdom (J.P.N., G.D.P.)
| | | | - Theresa M. Olasveengen
- Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway (T.M.O.)
| | - Judit Orosz
- Department of Medicine, The Alfred, Melbourne, Australia (J.O.)
| | - Gavin D. Perkins
- University of Warwick, Coventry, United Kingdom (J.P.N., G.D.P.)
| | | | | | | | | | - Paul S. Chan
- Mid-America Heart Institute, Kansas City, MO (P.S.C.)
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4
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Thomas K, Russell S. Advance Care Planning in the United Kingdom - A snapshot from the four UK nations. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:150-162. [PMID: 37541912 DOI: 10.1016/j.zefq.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/14/2023] [Accepted: 05/21/2023] [Indexed: 08/06/2023]
Abstract
The United Kingdom (UK) as a whole has a long-established decades-old history as an early adopter of the concepts of Advance Care Planning (ACP), with significant integration into mainstream national policy and widespread implementation. The ACP term itself, its processes, means, inclusions and implementations vary considerably within the UK and between its four nations, but the overall impression is of a strongly uniting consensus on the positive impact, value and vital importance of ACP in enabling better care for people in the final years of life, and at earlier life stages. Though there is always more work to do and more lessons to learn, those of us who have watched this world-wide movement grow over recent decades, find the overall direction of travel of commitment to mainstreaming ACP in the UK to be inspiring and encouraging, and gives us hope for the future. Across the UK, there is much shared history, policy, objectives, and regulation related to ACP, and at the same time, many variations in approach, tone, emphasis and detail within and between the four nations of the UK. The 2022 Office of National Statistics reports that the four nations of the UK have a combined population of 67 million (England 56.5 million, Scotland 5.5 million, Wales 3.1 million, Northern Ireland 1.9 million). All four nations are prioritising ACP as part of national policy, aiming to deliver more personalised care, particularly but not exclusively for those nearing the end of life, with a wide variety of best practice examples. Here we describe some common areas and variations across the UK history, policy and legal perspectives, some examples of best practice, resources, and exciting developments across all four nations which, although not exhaustive and within the limitations of our brief, reflect the flavour of our shared commitment. We are most grateful to all the contributing authors.
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Affiliation(s)
- Keri Thomas
- Gold Standards Framework Centre, London, UK.
| | - Sarah Russell
- Portsmouth Hospitals University NHS Trust, Hampshire, UK
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5
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Milling L, Nielsen DS, Kjær J, Binderup LG, de Muckadell CS, Christensen HC, Christensen EF, Lassen AT, Mikkelsen S. Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study. PLoS One 2023; 18:e0284826. [PMID: 37494384 PMCID: PMC10370897 DOI: 10.1371/journal.pone.0284826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/07/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA. METHODS We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis. RESULTS All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values. CONCLUSION This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.
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Affiliation(s)
- Louise Milling
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorthe Susanne Nielsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeannett Kjær
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Grassmé Binderup
- Department for the Study of Culture, Philosophy, University of Southern Denmark, Odense, Denmark
| | | | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Aalborg University, Aalborg, Denmark
- Emergency Medical Services, Region North Denmark, Aalborg, Denmark
| | | | - Søren Mikkelsen
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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6
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Meek T, Clyburn R, Fritz Z, Pitcher D, Ruck Keene A, Young PJ. Implementing advance care plans in the peri-operative period, including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline. Anaesthesia 2022; 77:456-462. [PMID: 35165886 DOI: 10.1111/anae.15653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/26/2022]
Abstract
Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.
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Affiliation(s)
- T Meek
- Department of Anaesthesia, James Cook University Hospital, Chair of Working Party, Association of Anaesthetists, London, UK, Middlesbrough, UK
| | - R Clyburn
- Grange University Hospital, Association of Anaesthetists, London, UK, Cwmbran, UK
| | - Z Fritz
- Department of Acute Medicine, Addenbrooke's Hospital, Cambridge and University of Cambridge, Cambridge, UK
| | - D Pitcher
- Resuscitation Council UK, London, UK
| | | | - P J Young
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Hospital, Association of Anaesthetists, London, UK, Kings Lynn, UK
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7
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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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8
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. [Adult advanced life support]. Notf Rett Med 2021; 24:406-446. [PMID: 34121923 PMCID: PMC8185697 DOI: 10.1007/s10049-021-00893-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Köln, Köln, Deutschland
| | - Pierre Carli
- SAMU de Paris, Center Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, Frankreich
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
- Warwick Medical School, University of Warwick, Coventry, Großbritannien
| | - Charles D. Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, Großbritannien
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, Großbritannien
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Schweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Schweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norwegen
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Pordenone, Italien
| | - Gavin D. Perkins
- Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, University of Warwick, Coventry, Großbritannien
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rom, Italien
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rom, Italien
| | - Jerry P. Nolan
- Warwick Medical School, Coventry, Großbritannien, Consultant in Anaesthesia and Intensive Care Medicine Royal United Hospital, University of Warwick, Bath, Großbritannien
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9
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Why, when and how do secondary-care clinicians have emergency care and treatment planning conversations? Qualitative findings from the ReSPECT Evaluation study. Resuscitation 2021; 162:343-350. [PMID: 33482270 DOI: 10.1016/j.resuscitation.2021.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an emergency care and treatment planning (ECTP) process, developed to offer a patient-centred approach to deciding about and recording treatment recommendations. Conversations between clinicians and patients or their representatives are central to the ReSPECT process. This study aims to understand why, when, and how ReSPECT conversations unfold in practice. METHODS ReSPECT conversations were observed in hospitals within six acute National Health Service (NHS) trusts in England; the clinicians who conducted these conversations were interviewed. Following observation-based thematic analysis, five ReSPECT conversation types were identified: resuscitation and escalation; confirmation of decision; bad news; palliative care; and clinical decision. Interview-based thematic analysis examined the reasons and prompts for each conversation type, and the level of detail and patient engagement in these different conversations. RESULTS Whereas resuscitation and escalation conversations concerned possible futures, palliative care and bad news conversations responded to present-tense changes. Conversations were timed to respond to organisational, clinical, and patient/relative prompts. While bad news and palliative care conversations included detailed discussions of treatment options beyond CPR, this varied in other conversation types. ReSPECT conversations varied in doctors' engagement with patient/relative preferences, with only palliative care conversations consistently including an open-ended approach. CONCLUSIONS While ReSPECT supports holistic, person-centred, anticipatory decision-making in some situations, a gap remains between the ReSPECT's aims and their implementation in practice. Promoting an understanding and valuing of the aims of ReSPECT among clinicians, supported by appropriate training and structural support, will enhance ReSPECT conversations.
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10
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Davies K. Resuscitation discussions: learning from Covid-19. CLINICAL TEACHER 2020; 18:206-207. [PMID: 33090681 PMCID: PMC7675728 DOI: 10.1111/tct.13278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Kristen Davies
- Northumbria Healthcare NHS Foundation TrustNorthumberlandUK
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11
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Hurst JR, Agarwal G, van Boven JFM, Daivadanam M, Gould GS, Wan-Chun Huang E, Maulik PK, Miranda JJ, Owolabi MO, Premji SS, Soriano JB, Vedanthan R, Yan L, Levitt N. Critical review of multimorbidity outcome measures suitable for low-income and middle-income country settings: perspectives from the Global Alliance for Chronic Diseases (GACD) researchers. BMJ Open 2020; 10:e037079. [PMID: 32895277 PMCID: PMC7478040 DOI: 10.1136/bmjopen-2020-037079] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/28/2020] [Accepted: 07/18/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES There is growing recognition around the importance of multimorbidity in low-income and middle-income country (LMIC) settings, and specifically the need for pragmatic intervention studies to reduce the risk of developing multimorbidity, and of mitigating the complications and progression of multimorbidity in LMICs. One of many challenges in completing such research has been the selection of appropriate outcomes measures. A 2018 Delphi exercise to develop a core-outcome set for multimorbidity research did not specifically address the challenges of multimorbidity in LMICs where the global burden is greatest, patterns of disease often differ and health systems are frequently fragmented. We, therefore, aimed to summarise and critically review outcome measures suitable for studies investigating mitigation of multimorbidity in LMIC settings. SETTING LMIC. PARTICIPANTS People with multimorbidity. OUTCOME MEASURES Identification of all outcome measures. RESULTS We present a critical review of outcome measures across eight domains: mortality, quality of life, function, health economics, healthcare access and utilisation, treatment burden, measures of 'Healthy Living' and self-efficacy and social functioning. CONCLUSIONS Studies in multimorbidity are necessarily diverse and thus different outcome measures will be appropriate for different study designs. Presenting the diversity of outcome measures across domains should provide a useful summary for researchers, encourage the use of multiple domains in multimorbidity research, and provoke debate and progress in the field.
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Affiliation(s)
- John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Gina Agarwal
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Meena Daivadanam
- Deptartment of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Food, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
- Department of Food Studies, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
- Deptartment of Global Public Health, Karolinska Institutet, Solna, Sweden
- International Maternal and Child Health Division, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Gillian Sandra Gould
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Erick Wan-Chun Huang
- Respiratory and Environmental Epidemiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
- Division of Thoracic Medicine, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
| | - Pallab K Maulik
- Research, The George Institute for Global Health, New Delhi, India
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Prasanna School of Public Health, Manipal, India
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - M O Owolabi
- Medicine, University of Ibadan College of Medicine, Ibadan, Nigeria
| | | | - Joan B Soriano
- Universidad Autónoma de Madrid, Madrid, Spain
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Rajesh Vedanthan
- Department of Population Health and Department of Medicine, NYU Langone Health, New York, New York, USA
| | - Lijing Yan
- Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Naomi Levitt
- Medicine, University of Cape Town, Cape town, South Africa
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12
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Antunes B, Bowers B, Winterburn I, Kelly MP, Brodrick R, Pollock K, Majumder M, Spathis A, Lawrie I, George R, Ryan R, Barclay S. Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. BMJ Support Palliat Care 2020; 10:343-349. [PMID: 32546559 PMCID: PMC7335692 DOI: 10.1136/bmjspcare-2020-002394] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/01/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Anticipatory prescribing (AP) of injectable medications in advance of clinical need is established practice in community end-of-life care. Changes to prescribing guidelines and practice have been reported during the COVID-19 pandemic. AIMS AND OBJECTIVES To investigate UK and Ireland clinicians' experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change. METHODS Online survey of participants at previous AP national workshops, members of the Association for Palliative Medicine of Great Britain and Ireland and other professional organisations, with snowball sampling. RESULTS Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). Recommendations for regulatory changes to permit drug repurposing and easier community access were made. CONCLUSIONS The challenges of the COVID-19 pandemic for UK community palliative care has stimulated rapid innovation in AP. The extent to which these are implemented and their clinical efficacy need further examination.
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Affiliation(s)
- Bárbara Antunes
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
| | - Ben Bowers
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
| | - Isaac Winterburn
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
| | - Michael P Kelly
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
| | - Robert Brodrick
- Community Specialist Palliative Care Team, Arthur Rank Hospice Charity, Cambridge, UK
- Palliative Medicine, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Kristian Pollock
- School of Nursing, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Megha Majumder
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
| | - Anna Spathis
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
| | - Iain Lawrie
- Palliative Medicine, North Manchester General Hospital, Manchester, UK
- Manchester Medical School, The University of Manchester, Manchester, UK
| | - Rob George
- Medicine, St Christopher's Hospice, London, UK
- Cicely Saunders Institute, King's College London School of Medical Education, London, UK
| | - Richella Ryan
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
- Community Specialist Palliative Care Team, Arthur Rank Hospice Charity, Cambridge, UK
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge Primary Care Unit, Cambridge, Cambridgeshire, UK
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A brave new world: the new normal for general practice after the COVID-19 pandemic. BJGP Open 2020; 4:bjgpopen20X101103. [PMID: 32487520 PMCID: PMC7465568 DOI: 10.3399/bjgpopen20x101103] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/15/2020] [Indexed: 10/31/2022] Open
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Sowden S, Nezafat-Maldonado B, Wildman J, Cookson R, Thomson R, Lambert M, Beyer F, Bambra C. Interventions to reduce inequalities in avoidable hospital admissions: explanatory framework and systematic review protocol. BMJ Open 2020; 10:e035429. [PMID: 32709641 PMCID: PMC7380849 DOI: 10.1136/bmjopen-2019-035429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Internationally there is pressure to contain costs due to rising numbers of hospital admissions. Alongside age, socioeconomic disadvantage is the strongest risk factor for avoidable hospital admission. This equity-focussed systematic review is required for policymakers to understand what has been shown to work to reduce inequalities in hospital admissions, what does not work and where the current gaps in the evidence-base are. METHODS AND ANALYSIS An initial framework shows how interventions are hypothesised to reduce socioeconomic inequalities in avoidable hospital admissions. Studies will be included if the intervention focusses exclusively on socioeconomically disadvantaged populations or if the study reports differential effects by socioeconomic status (education, income, occupation, social class, deprivation, poverty or an area-based proxy for deprivation derived from place of residence) with respect to hospital admission or readmission (overall or condition-specific for those classified as ambulatory care sensitive). Studies involving individuals of any age, undertaken in OECD (Organisation for Economic Co-operation and Development) countries, published from 2000 to 29th February 2020 in any language will be included. Electronic searches will include MEDLINE, Embase, CINAHL, Cochrane CENTRAL and the Web of Knowledge platform. Electronic searches will be supplemented with full citation searches of included studies, website searches and retrieval of relevant unpublished information. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Narrative synthesis will be conducted and also meta-analysis where possible. The main analysis will examine the effectiveness of interventions at reducing socioeconomic inequalities in hospital admissions. Interventions will be characterised by their domain of action and approach to addressing inequalities. For included studies, contextual information on where, for whom and how these interventions are organised, implemented and delivered will be examined where possible. ETHICS AND DISSEMINATION Ethical approval was not required for this protocol. The research will be disseminated via peer-reviewed publication, conferences and an open-access policy-orientated paper. PROSPERO REGISTRATION NUMBER CRD42019153666.
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Affiliation(s)
- Sarah Sowden
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Josephine Wildman
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Richard Cookson
- Centre for Health Economics, University of York, York, North Yorkshire, UK
| | - Richard Thomson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Lambert
- North East Centre, Public Health England, Newcastle upon Tyne, UK
| | - Fiona Beyer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive 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.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA 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.ResultsInfluences 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.LimitationsLimitations 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.ConclusionsDecision-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 workFurther 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 registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe 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.
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Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
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Cahill S. Should Human Rights and Autonomy be The Primary Determinants for the Disclosure of a Decision to Withhold Futile Resuscitation? New Bioeth 2019; 25:39-59. [PMID: 30779695 DOI: 10.1080/20502877.2019.1574133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Do not attempt cardiopulmonary resuscitation decisions (DNACPR) are considered good medical practice for those dying at the end of natural life. They avoid intrusive and inappropriate intervention. Historically, informing patients of these decisions was discretionary to avoid undue distress. Recent legal rulings have altered clinical guidance: disclosure is now all but obligatory. The basis for these legal judgments was respect for the patient's autonomy as an expression of their human rights. Through critical analysis, this paper explores other bioethical considerations and the potential harms if they are ignored. Arguably, disclosure of DNACPR status on its own will do little to improve patient experience. A focus on good communication with those identified as approaching end-of-life will facilitate personalized care. Discussions around DNACPR may still occur, but only if likely to be beneficial and at a patient-appropriate pace (not dictated by the need to activate the decision).
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Affiliation(s)
- Sarah Cahill
- a Institute of Theology , St Mary's University , Twickenham, London , UK
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Abstract
Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services' staff. However, the best approaches for airway management and the effectiveness of currently used drug treatments are uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.
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Affiliation(s)
- Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France; Paris Descartes University, Paris, France
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Power N, Plummer NR, Baldwin J, James FR, Laha S. Intensive care decision-making: Identifying the challenges and generating solutions to improve inter-specialty referrals to critical care. J Intensive Care Soc 2018; 19:287-298. [PMID: 30515238 DOI: 10.1177/1751143718758933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Decision-making regarding admission to UK intensive care units is challenging. Demand for beds exceeds capacity, yet the need to provide emergency cover creates pressure to build redundancy into the system. Guidelines to aid clinical decision-making are outdated, resulting in an over-reliance on professional judgement. Although clinicians are highly skilled, there is variability in intensive care unit decision-making, especially at the inter-specialty level wherein cognitive biases contribute to disagreement. Method This research is the first to explore intensive care unit referral and admission decision-making using the Critical Decision Method interviewing technique. We interviewed intensive care unit (n = 9) and non-intensive care unit (n = 6) consultants about a challenging referral they had dealt with in the past where there was disagreement about the patient's suitability for intensive care unit. Results We present: (i) a description of the referral pathway; (ii) challenges that appear to derail referrals (i.e. process issues, decision biases, inherent stressors, post-decision consequences) and (iii) potential solutions to improve this process. Discussion This research provides a foundation upon which interventions to improve inter-specialty decision-making can be based.
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Affiliation(s)
- Nicola Power
- Department of Psychology, Lancaster University, UK
| | - Nicholas R Plummer
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.,Health Education East Midlands, Leicester, UK
| | - Jacqueline Baldwin
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Fiona R James
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Shondipon Laha
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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Moffat S, Skinner J, Fritz Z. Does resuscitation status affect decision making in a deteriorating patient? Results from a randomised vignette study. J Eval Clin Pract 2016; 22:917-923. [PMID: 27237130 PMCID: PMC5111586 DOI: 10.1111/jep.12559] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
AIMS AND OBJECTIVES The aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options ('UFTO': an alternative approach that contextualizes the resuscitation decision within an overall treatment plan) on nurses' decision making about a deteriorating patient. METHODS An online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no-form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures. RESULTS Reported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no-form groups (P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments (all P < 0.001). There was no difference between the UFTO and no-form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups. CONCLUSION The presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no-form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care.
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Affiliation(s)
- Suzanne Moffat
- Health Sciences, University of East Anglia, Norwich, Norfolk, UK
| | - Jane Skinner
- Department of Medicine, University of East Anglia, Norwich, Norfolk, UK
| | - Zoë Fritz
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
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