1598P - Escalation plans and DNACPR discussions in the unwell oncology patient

Abstract

BackgroundPatients with advanced end stage cancer have < 1% chance of spontaneous circulation following cardiopulmonary resuscitation (CPR). Effective communication in a timely manner is best practice to ensure DNACPR (Do not attempt cardiopulmonary resuscitation) decisions are implemented correctly, well understood by patients/relatives and to avoid unnecessary CPR. Previous audit data at LRI and clinician experience indicated that oncology inpatients were having significant delays in DNACPR discussions. In many cases DNACPR decisions were occurring in emergency clinical situations by out of hours on-call medical staff. MethodsWe identified unwell (early warning score >5) oncology inpatients admitted to LRI. Using a data collection tool, we primarily identified the proportion of patients who had a DNACPR decision. Furthermore, we analysed timeliness of DNACPR decisions, involvement of patients’ own oncology team and documentation of prognosis/escalation plans. Liaising with healthcare professionals from oncology & palliative care we formulated ideas to improve outcomes. Enhancing communication between permanent ward staff (nurses & junior doctors) and senior decision makers (oncology registrars & consultants) was vital to improve outcomes. We therefore empowered junior doctors/nursing staff to identify patients who needed DNACPR discussions using a proforma tool utilising board round meetings as a platform. Data was then analysed to compare outcomes. ResultsQualitative data showed improved confidence for junior doctors in identifying & communicating DNACPR discussions.Table1598PTableBefore InterventionAfter InterventionDNACPR discussed by own team11%54%DNACPR discussed by oncology team29%92%DNACPR discussed in daytime24%77%Mean time to implement DNACPR4 days2.5 daysDNACPR implemented and patient discharged home5%54%DNACPR not implemented in eligible patient – died following CPR44%12%Documentation of escalation plan30%85%Documentation of prognosis25%54% ConclusionsEmpowering junior doctors and simple departmental changes lead to a significant improvement in communicating and implementing DNACPR decisions. We therefore significantly reduced unnecessary CPR attempts and subsequently improved communication and documentation of escalation plans and prognosis. We believe our model can be implemented in other oncology centres and look forward to discussing this further. Legal entity responsible for the studyNational Health Service, UK. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.