Resuscitation (un-)wanted: Does anyone care? A retrospective real data analysis

BACKGROUND AND OBJECTIVES

In case of out-of-hospital cardiac arrest (OHCA) personnel of the emergency medical services (EMS) are regularly confronted with advanced directives (AD) and do-not-attempt-resuscitation (DNACPR) orders. The authors conducted a retrospective analysis of EMS operation protocols to examine the prevalence of DNACPR in case of OHCA and the influence of a presented DNACPR on CPR-duration, performed Advanced-Life-Support (ALS) measures and decision making.

MATERIALS AND METHODS

Retrospective analysis of prehospital medical documentation of all resuscitation incidents in a German county with 250,000 inhabitants from 1 January 2016 to 31 December 2022. Combined with data from the structured CPR team-feedback database patients characteristics, measures and course of the CPR were analysed. Statistic testing with significance level p < 0.05.

RESULTS

In total n = 1,474 CPR events were analysed. Patients with DNACPR vs. no DNACPR: n = 263 (17.8%) vs. n = 1,211 (82.2%). Age: 80.0 ± 10.3 years vs. 68.0 ± 13.9 years; p < 0.001. Patients with ASA-status III/IV: n = 214 (81.3%) vs. n = 616 (50.9%); p < 0.001. Initial layperson-CPR: n = 148 (56.3%) vs. n = 647 (55.7%); p = 0.40. Airway management: n = 185 (70.3%) vs. n = 1,069 (88.3%); p < 0.001. With DNACPR CPR-duration initiated layperson-CPR vs. no layperson-CPR: 19:14 min (10:43-25:55 min) vs. 12:40 min (06:35-20:03 min); p < 0.001.

CONCLUSION

In case of CPR EMS-personnel are often confronted with DNACPR-orders. Patients are older and have more previous diseases than patients without DNACPR. Initiated layperson-CPR might lead to misinterpretation of patients will with impact on CPR-duration and unwanted measures. Awareness of this issue should be created through measures such as training programs in particular to train staff in the interpretation and legal admissibility of ADs.

Peri-operative cardiac arrest in the older frail patient as reported to the 7th National Audit Project of the Royal College of Anaesthetists

Frailty increases peri-operative risk, but details of its burden, clinical features and the risk of, and outcomes following, peri-operative cardiac arrest are lacking. As a preplanned analysis of the 7th National Audit Project of the Royal College of Anaesthetists, we described the characteristics of older patients living with frailty undergoing anaesthesia and surgery, and those reported to the peri-operative cardiac arrest case registry. In the activity survey, 1676 (26%) of 6466 patients aged > 65 y were reported as frail (Clinical Frailty Scale score ≥ 5). Increasing age and frailty were both associated with increasing comorbidities and the proportion of surgery undertaken as an emergency. Except in patients who were terminally ill (Clinical Frailty Scale score 9), increasing frailty was associated with an increased proportion of complex or major surgery. The rate of use of invasive arterial blood pressure monitoring was associated with frailty only until Clinical Frailty Scale score 5, and then plateaued or fell. Of 881 cardiac arrests reported to the 7th National Audit Project, 156 (18%) were in patients aged > 65 y and living with frailty, with an estimated incidence of 1 in 1204 (95%CI 1 in 1027-1412) and a mortality rate of 1 in 2020 (95%CI 1 in 1642-2488), approximately 2.6-fold higher than in adults who were not frail. Hip fracture, emergency laparotomy, emergency vascular surgery and urological surgery were the most common surgical procedures in older patients living with frailty who had a cardiac arrest. We report a high burden of frailty within the surgical population, requiring complex, urgent surgery, and the extent of poorer outcomes of peri-operative cardiac arrest compared with patients of the same age not living with frailty.

Peri-operative decisions about cardiopulmonary resuscitation among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists

Current guidance recommends that, in most circumstances, cardiopulmonary resuscitation should be attempted when cardiac arrest occurs during anaesthesia, and when a patient has a pre-existing 'do not attempt cardiopulmonary resuscitation' recommendation, this should be suspended. How this guidance is translated into everyday clinical practice in the UK is currently unknown. Here, as part of the 7th National Audit Project of the Royal College of Anaesthetists, we have: assessed the rates of pre-operative 'do not attempt cardiopulmonary resuscitation' recommendations via an activity survey of all cases undertaken by anaesthetists over four days in each participating site; and analysed our one-year case registry of peri-operative cardiac arrests to understand the rates of cardiac arrest in patients who had 'do not attempt cardiopulmonary resuscitation' decisions pre-operatively. In the activity survey, among 20,717 adults (aged > 18 y) undergoing surgery, 595 (3%) had a 'do not attempt cardiopulmonary resuscitation' recommendation pre-operatively, of which less than a third (175, 29%) were suspended. Of the 881 peri-operative cardiac arrest reports, 54 (6%) patients had a 'do not attempt cardiopulmonary resuscitation' recommendation made pre-operatively and of these 38 (70%) had a clinical frailty scale score ≥ 5. Just under half (25, 46%) of these 'do not attempt cardiopulmonary resuscitation' recommendations were formally suspended at the time of anaesthesia and surgery. One in five of these patients with a 'do not attempt cardiopulmonary resuscitation' recommendation who had a cardiac arrest survived to leave hospital and of the seven patients with documented modified Rankin Scale scores before and after cardiac arrest, four remained the same and three had worse scores. Very few patients who had a pre-existing 'do not attempt cardiopulmonary resuscitation' recommendation had a peri-operative cardiac arrest, and when cardiac arrest did occur, return of spontaneous circulation was achieved in 57%, although > 50% of these patients subsequently died before discharge from hospital.

To withhold resuscitation - The Swedish system's rules and challenges

The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision "Do-Not-Attempt-Cardio-Pulmonary-Resuscitation" (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6-13% of patients dying in Swedish hospitals. According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will. Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions. We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.

Advance Care Planning and Place of Death During the COVID-19 Pandemic: A Retrospective Analysis of Routinely Collected Data

Increased advance care planning was endorsed at the start of the Coronavirus disease 2019 (COVID-19) pandemic with the aim of optimizing end-of-life care. This retrospective observational cohort study explores the impact of advanced care planning on place of death. 21,962 records from patients who died during the first year of the pandemic and who had an Electronic Palliative Care Coordination System record were included. 11,913 (54%) had a documented place of death. Of these 5,339 died at home and 2,378 died in hospital. 9,971 (45%) had both a documented place of death and a preferred place of death. Of these, 7,668 (77%) died in their preferred location. Documented elements of advance care planning, such as resuscitation status and ceiling of treatment decisions, were associated with an increased likelihood of dying in the preferred location, as were the number of times the record was viewed. During the COVID-19 pandemic, advanced care planning and the use of digital care coordination systems presented an opportunity for patients and healthcare staff to personalize care and influence end-of-life experiences.

The experiences of adult patients, families, and healthcare professionals of CPR decision-making conversations in the United Kingdom: A qualitative systematic review

Aim

To conduct a qualitative systematic review on the experiences of patients, families, and healthcare professionals (HCPs) of CPR decision-making conversations in the United Kingdom (UK).

Methods

The databases PubMed, Embase, Emcare, CINAHL, and PsycInfo were searched. Studies published from 1 January 2012 describing experiences of CPR decision-making conversations in the UK were included. Included studies were critically appraised using the CASP tool. Thematic synthesis was conducted.

Results

From 684 papers identified, ten studies were included. Four key themes were identified:(i) Initiation of conversations - Key prompts for the discussion included clinical deterioration and poor prognosis. There are different perspectives about who should initiate conversations.(ii) Involvement of patients and families - HCPs were reluctant to involve patients who they thought would become distressed by the conversation, while patients varied in their desire to be involved. Patients wanted family support while HCPs viewed families as potential sources of conflict.(iii) Influences on the content of conversations - Location, context, HCPs' attitudes and emotions, and uncertainty of prognosis influenced the content of conversations.(iv) Conversation outcomes - Range of outcomes included emotional distress, sense of relief and value, disagreements, and incomplete conversations.

Conclusions

There is inconsistency in how these conversations occur, patients' desire to be involved, and between patients' and HCPs' views on the role of families in these conversations. CPR discussions raise ethical challenges for HCPs. HCPs need training and pastoral support in conducting CPR discussions. Patients and families need education on CPR recommendations and support after discussions.

Pre-operative resuscitation discussion with patients undergoing fractured neck of femur repair: a service evaluation and discussion of current standards

INTRODUCTION

The majority of neck of femur (NOF) fracture patients are frail and at a higher risk of cardiac arrest. This makes discussion of treatment escalation vital to informed care. The optimal time for these discussions is prior to admission or trauma. However, when this has not occurred, it is vital that these discussions happen early in the patient's admission when family is often present and before further deterioration in their condition. We undertook a service evaluation to evaluate and discuss the effect of clinician education on improving rates of timely discussion amongst orthopaedic doctors.

MATERIALS AND METHODS

The first cycle included 94 patients. Their notes were reviewed for presence of a ReSPECT (Recommend Summary Plan for Emergency Care and Treatment) form prior to operation and whether this it countersigned by a consultant. Following this, clinician education was undertaken and a re-audit was carried out involving 57 patients.

RESULTS

ReSPECT form completion rates rose from 23% in cycle 1-32% in cycle 2 following intervention. The proportion which consultants signed rose from 41% to 56% following intervention.

CONCLUSION

This project demonstrates how a basic education program can prove limited improvements in the rates of timely resuscitation discussions. We discuss a current lack in quality research into educational programs for discussion of treatment escalation for orthopaedic trainees. We suggest there is room to improve national best practice guidelines and training to ensure these discussions are carried out more frequently and to a better standard.

Implementation of ReSPECT in acute hospitals: A retrospective observational study

AIMS

To evaluate, in UK acute hospitals, the early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans. To understand for whom and how the process was being used and the quality of form completion.

METHODS

A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes.

RESULTS

The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement.

CONCLUSIONS

ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement.

STUDY REGISTRATION

https://www.isrctn.com/ISRCTN11112933.

Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings

Background

We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT).

Methods

A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period.

Results

Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or ‘not eligible for intensive care’ (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician.

Conclusion

Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01002-8.

DNACPR decisions during Covid-19: An empirical and analytical study

Considerable concern has arisen during the Covid pandemic over the use of Do Not Attempt Cardiopulmonary Resuscitation decisions (DNACPRs) in England and Wales, particularly around the potential blanket application of them on older adults and those with learning disabilities. In this article, we set out the legal background to DNACPRs in England and the concerns raised during Covid. We also report on an empirical study that examined the use of DNACPRs across 23 Trusts in England, which found overall increases in the number of patients with a DNACPR decision during the two main Covid 'waves' (23 March 2020-31 January 2021) compared with the previous year. We found that these increases were largest among those in mid-life age groups, despite older patients (in particular, older women) having a higher number of DNACPR decisions overall. However, further analysis revealed that DNACPR decisions remained fairly consistent with regard to patient sex and age, with small reductions seen in the oldest age groups. We found that a disproportionate number of Black Caribbean patients had a DNACPR decision. Overall, approximately one in five patients was not consulted about the DNACPR decision, but during the first Covid wave more patients were consulted than pre-Covid.

General practitioners' experiences of emergency care and treatment planning in England: a focus group study

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.

Low adherence to legislation regarding Do-Not-Attempt-Cardiopulmonary-Resuscitation orders in a Swedish University Hospital

Background

The ethical principles of resuscitation have been incorporated into Swedish legislation so that a decision to not attempt cardiopulmonary resuscitation (DNACPR) entails (1) consultation with patient or relatives if consultation with patient was not possible and documentation of their attitudes; (2) consultation with other licensed caregivers; (3) documentation of the grounds for the DNACPR. Our aim was to evaluate adherence to this legislation, explore the grounds for the decision and the attitudes of patients and relatives towards DNACPR orders.

Methods

We included DNACPR forms issued after admission through the emergency department at Karolinska University Hospital between 1st January and 31st October, 2015. Quantitative analysis evaluated adherence to legislation and qualitative analysis of a random sample of 20% evaluated the grounds for the decision and the attitudes.

Results

The cohort consisted of 3583 DNACPR forms. In 40% of these it was impossible to consult the patient, and relatives were consulted in 46% of these cases. For competent patients, consultation occurred in 28% and the most common attitude was to wish to refrain from resuscitation. Relatives were consulted in 26% and they mainly agreed with the decision. Grounds for the DNAR decision was most commonly severe chronic comorbidity, malignancy or multimorbidity with or without an acute condition. All requirements of the legislation were fulfilled in 10% of the cases.

Conclusion

In 90% of the cases physicians failed to fulfil all requirements in the Swedish legislation regarding DNAR orders. The decision was mostly based on chronic, severe comorbidity or multimorbidity.

Advance care planning for patients with COVID-19: a communication guide

In view of the high morbidity and mortality associated with COVID-19, early and honest conversations with patients about goals of care are vital. Advance care planning in its traditional manner may be difficult to achieve given the unpredictability of the disease trajectory. Despite this, it is crucial that patients' care wishes are explored as this will help prevent inappropriate admissions to hospital and to critical care, improve symptom control and advocate for patient choice. This article provides practical tips on how to translate decisions around treatment escalation plans into conversations, both face-to-face and over the phone, in a sensitive and compassionate manner. Care planning conversations for patients with COVID-19 should be individualised and actively involve the patient. Focusing on goals of care rather than ceilings of treatment can help to alleviate anxiety around these conversations and will remind patients that their care will never cease. Using a framework such as the 'SPIKES' mnemonic can help to structure this conversation. Verbally conveying empathy will be key, particularly when wearing personal protective equipment or speaking to relatives over the phone. It is also important to make time to recognise your own emotions during and/or after these conversations.

Recognising the elephant in the room: Foundation doctors and anticipatory care planning

Anticipatory/advance care planning (ACP) conversations are often known to be challenging and should be undertaken sensitively. A qualitative service evaluation was undertaken with the elderly care department at The Leeds Teaching Hospitals NHS Trust by medical students to explore the thoughts and experiences of foundation doctors. ACP discussions include consideration of future treatment options and preferences; however, foundation doctors were not confident to discuss issues beyond resuscitation status. The key themes identified include understanding of and confidence in ACP, variation across specialty and medical educational needs. The analysis highlights a further need for qualitative research into prevalent attitudes towards ACP discussions across the range of specialties.

The impact of the Tracey judgment on the rates and outcomes of in-hospital cardiac arrests in UK hospitals participating in the National Cardiac Arrest Audit

AIMS

The aim was to determine if the 17 June 2014 Tracey judgment regarding 'do not attempt cardiopulmonary resuscitation' decisions led to increases in the rate of in-hospital cardiac arrests resulting in a resuscitation attempt (IHCA) and/or proportion of resuscitation attempts deemed futile.

METHOD

Using UK National Cardiac Arrest Audit data, the IHCA rate and proportion of resuscitation attempts deemed futile were compared for two periods (pre-judgment (01 July 2012 - 16 June 2014, inclusive) and post-judgment (01 July 2014 - 30 June 2016, inclusive)) using interrupted time series analyses.

RESULTS

A total of 43,109 IHCAs (115 hospitals) were analysed. There were fewer IHCAs post- than pre-judgment (21,324 vs 21,785, respectively). The IHCA rate was declining over time before the judgment but there was an abrupt and statistically significant increase in the period immediately following the judgment (p<0.001). This was not sustained post-judgment. The proportion of resuscitation attempts deemed futile was smaller post-judgment than pre-judgment (8.2% vs 14.9%, respectively). The rate of attempts deemed futile decreased post-judgment (p<0.001).

CONCLUSION

The IHCA rate increased immediately after the Tracey judgment while the proportion of resuscitation attempts deemed futile decreased. The precise mechanisms for these changes are unclear.

From paper to paperless: Do electronic systems ensure safe and effective communication and documentation of DNACPR decisions?

INTRODUCTION

An electronic resuscitation system, implemented in 2015, within electronic patient records (EPR) at King's College Hospital NHS Foundation Trust was studied, aiming to review and improve decision documentation and communication.

METHOD

The study (January 2018 - June 2018) included all gerontology inpatients with electronic do not attempt cardiopulmonary resuscitation (e-DNACPR) decisions. Cases were identified weekly, followed by retrospective analysis of discharges. Amendments to the electronic system and improvements were implemented between cycles. CYCLE 1: One-hundred and thirty-three patients were included; 85% had an e-DNACPR form; 86% of all forms had senior doctor involvement; 68% evidenced patient/relative discussion; 13% documented multidisciplinary team (MDT) discussion.

INTERVENTIONS

A mandatory 'named nurse' field was added to the form and trust-wide education programme implemented. CYCLE 2: One-hundred and twenty-six patients were included; 100% had an e-DNACPR form; 93% evidenced senior doctor involvement; 71% evidenced patient/relative discussion; 57% documented MDT discussion.

CONCLUSION

Changes to the process and trust-wide education resulted in more robust documentation and communication.

Development of the Recommended Summary Plan for eEmergency Care and Treatment (ReSPECT)

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.

Should Human Rights and Autonomy be The Primary Determinants for the Disclosure of a Decision to Withhold Futile Resuscitation?

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).

Doctors Are Inconsistent in Estimating Survival after CPR and Are Not Using Such Predictions Consistently in Determining DNACPR Decisions

Background: It is unclear whether doctors base their resuscitation decisions solely on their perceived outcome. Through the use of theoretical scenarios, we aimed to examine the 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision-making. Methods: A questionnaire survey was sent to consultants and specialty trainees across two Norfolk (UK) hospitals during December 2013. The survey included demographic questions and six clinical scenarios with varying prognosis. Participants were asked if they would resuscitate the patient or not. Identical scenarios were then shown in a different order and doctors were asked to quantify patients' estimated chance of survival. Results: A total of 137 individuals (mean age 41 years (SD 7.9%)) responded. The response rate was 69%. Approximately 60% were consultants. We found considerable variation in clinician estimates of median chance of survival. In three out of six of our scenarios, the survival estimated varied from <1% to 95%. There was a statistically significant difference identified in the estimated median survival between those clinicians who would or would not resuscitate in four of the six scenarios presented. Conclusion: This study has highlighted the wide variation between clinicians in their estimates of likely survival and little concordance between clinicians over their resuscitation decisions. The diversity in clinician decision-making should be explored further.

Talk CPR - a technology project to improve communication in do not attempt cardiopulmonary resuscitation decisions in palliative illness

Background

A national Do Not Attempt Cardiopulmonary Resuscitation policy was rolled out for the National Health Service in Wales in 2015. A national steering group led on producing information videos and a website for patients, carers and healthcare professionals, forming part of a quality improvement program. Videos were planned, scripted and produced with healthcare professionals and patient/carer representatives, and were completed with both English and Welsh language versions. The TalkCPR videos encourage and promote open discussion about Cardiopulmonary Resuscitation (CPR) and DNACPR in palliative care situations.

Methods

We worked with patient/carer groups to evaluate whether video resources to convey the salient facts involved in CPR and DNACPR decisions for people with palliative and life-limiting illness were acceptable or not. We conducted a mixed-method design service review in five phases to evaluate whether this technological resource could help. After creating video and website materials, they were evaluated by doctors, nurses and a patient/carer group. We also sent out one lightweight TalkCPR video media pad to each practice in Wales. These rechargeable electronic video media pads had communication videos pre-loaded for easy viewing, especially in areas with poor roaming data coverage.

Results

Videos were demonstrably acceptable to both patient and carer groups, and improved healthcare professional confidence and understanding. Videos went live on the TalkCPR website, in all Welsh Health Boards and on Youtube, and are now used in routine practice throughout Wales.

Conclusion

This is the first time that DNACPR information videos are aimed directly at palliative care patients and carers, to explore this sensitive subject with them, and to encourage them to approach their doctor or nurse about it. The website, app and video media pads were developed by patients, the Digital Legacy Association, Welsh NHS IT services, Welsh Government, the Bevan Commission and the Dying Matters Charity in Wales ‘Byw Nawr’. The GMC, the Royal College of General Practitioners and NICE have listed TalkCPR as a learning resource. There has also been a collaboration with Falmouth University Art College, who helped produce graphic designs to facilitate and encourage discussions about CPR and end of life care.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0370-9) contains supplementary material, which is available to authorized users.

Medical students' experiences of resuscitation and discussions surrounding resuscitation status

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.

Discussion and documentation of future care: a before-and-after study examining the impact of an alternative approach to recording treatment decisions on advance care planning in an acute hospital

OBJECTIVE

To determine whether discussion and documentation of decisions about future care was improved following the introduction of a new approach to recording treatment decisions: the Universal Form of Treatment Options (UFTO).

METHODS

Retrospective review of the medical records of patients who died within 90 days of admission to oncology or respiratory medicine wards over two 3-month periods, preimplementation and postimplementation of the UFTO. A sample size of 70 per group was required to provide 80% power to observe a change from 15% to 35% in discussion or documentation of advance care planning (ACP), using a two-sided test at the 5% significance level.

RESULTS

On the oncology ward, introduction of the UFTO was associated with a statistically significant increase in cardiopulmonary resuscitation decisions documented for patients (pre-UFTO 52% to post-UFTO 77%, p=0.01) and an increase in discussions regarding ACP (pre-UFTO 27%, post-UFTO 49%, p=0.03). There were no demonstrable changes in practice on the respiratory ward. Only one patient came into hospital with a formal ACP document.

CONCLUSIONS

Despite patients' proximity to the end-of-life, there was limited documentation of ACP and almost no evidence of formalised ACP. The introduction of the UFTO was associated with a change in practice on the oncology ward but this was not observed for respiratory patients. A new approach to recording treatment decisions may contribute to improving discussion and documentation about future care but further work is needed to ensure that all patients' preferences for treatment and care at the end-of-life are known.

DNACPR ('do not attempt cardiopulmonary resuscitation') orders in patients with a fractured neck of femur who lack capacity

Nationally, half of all deaths occur in hospital, with 94% having a 'do not attempt cardiopulmonary resuscitation' (DNACPR) notice in place at the time of death. Recent court rulings have raised the profile of practices surrounding DNACPR orders where patients lack capacity. Failure to consult with those close to the patient in relation to DNACPR decisions is a breach of the right to respect for private and family life under article 8 of the Human Rights Act. A report from 2016 found that those close to the patient were not consulted before one out of every five DNACPR orders are placed. We advocate addressing the issue of resuscitation in patients with a fractured neck of femur who are approaching the end of their lives. Where the patient lacks capacity, there is a legal duty to consult with those close to the patient where it is practicable and appropriate to do so. There must be a convincing and well evidenced reason to proceed without consultation, and the orthopaedic surgeon should exercise extreme caution before doing so.

Limitation of care orders in patients with a diagnosis of dementia

The prevalence of dementia is growing with an ageing population. Most persons with dementia die of acute illness and many are hospitalised at the end of life. In the acute hospital setting, limitation of care orders (LCOs) such as Do Not Attempt CPR and Physician Orders For Life Sustaining Treatment (POLST), appear to be underused in patients with dementia. These patients receive the same aggressive life-prolonging therapies as any other patient, despite drastically higher mortality. However, limitation of care orders in patients with dementia is not addressed by current guidelines or policies. Systems and processes for obtaining and documenting LCO need improvement at the individual, organisational and societal level. The issue is controversial amongst the public and poorly understood by clinicians. Balanced and empathetic decision-making requires an individualised approach and recognition of the complexities (legal, ethical and clinical) of this issue. We examine the domains of: (a) treatment effectiveness, (b) burden of care and quality of life and (c) patient autonomy and capacity.

TRACEY AND RESPECT FOR AUTONOMY: WILL THE PROMISE BE DELIVERED?

The central issue of the Court of Appeal decision in R (Tracey) v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] EWCA Civ 822 concerned whether competent adults should be involved in the decision-making process for Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) decisions. These are sensitive decisions made on the basis that cardio-pulmonary resuscitation would be futile, or that efforts to resuscitate would not be in the best clinical interests of the person concerned. The Court held that patient involvement in DNACPR decisions should be the presumption, even if clinicians sincerely believed that resuscitation would be futile, unless that involvement would cause actual psychological or physical harm. This case commentary explores the potential implications of this decision in the context of contemporary healthcare.

DNACPR decisions: challenging and changing practice in the wake of the Tracey judgment

The Court of Appeal judgment that Janet Tracey's human rights had been breached when a 'do not attempt cardiopulmonary resuscitation' (DNACPR) form was written about her without her knowledge has far-reaching implications for clinical practice. The 'duty to consult' extends to all patients apart from those in whom it is likely that discussion would cause 'physical or psychological harm'. The ethical basis for this judgment is strong: if a patient is unaware that a resuscitation decision has been made, he or she cannot ask questions, plan the future or ask for second opinions. Clinicians have, however, expressed concerns about the logistic implications of this judgment in terms of time and resource allocation, and the possibility that doctors will refrain from making resuscitation decisions at all, rather than risk uncomfortable discussions or litigation. Problems with DNACPR decisions predate the Tracey case, and a coordinated alternative approach is needed: patients should be given information so that they can anticipate, initiate and participate in discussions; resuscitation decisions should be considered early in treatment, in a community setting or at predictable junctures; resuscitation should not be considered in isolation but within the context of other goals of care. Models addressing these issues have been developed.

Characteristics and outcome of patients with DNACPR orders in an acute hospital; an observational study

AIMS

To establish the characteristics and outcomes of patients with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders; to assess whether particular patient characteristics are associated with discussing resuscitation orders with patients.

METHODS

Retrospective case note analysis from an acute hospital in 2009 was performed on: all in-hospital deaths; all patients who had carbon-copies of their DNACPR forms returned to the resuscitation department and a sample of age-matched discharged patients without known DNACPR order forms. Univariate and multivariate logistic regression analysis was used to test the significance of the associations and calculate odds ratios.

RESULTS

Of 541 sampled patients, 51% of patients with DNACPR orders were discharged. Baseline characteristics of those who had in-hospital deaths or were discharged with DNACPR orders were similar. The overall one-year mortality for patients with a DNACPR order was 83%. 50% of patients had documentation of having DNACPR orders discussed: this was consistent across patient characteristics including those who were discharged and those who had in-hospital deaths. Cases of "inappropriate" resuscitation attempts were identified.

CONCLUSIONS

About half of patients with DNACPR orders were discharged home, and 17% were alive at one year. Characteristics of patients and frequency of discussions were similar in those who died or were discharged. Current focus of use of DNACPR orders only on those identified as most likely to die makes inappropriate resuscitation attempt a likely occurrence, and care is required to ensure conflation with "end of life" pathways does not distort the treatments given to this vulnerable group.