Usage of do-not-attempt-to-resuscitate orders in a Swedish community hospital \u2013 patient involvement, documentation and compliance

Emilie Bertilsson,Kristina Schildmeijer,Jörg Carlsson,Anders Bremer,Birgitta Semark

doi:10.1186/s12910-020-00510-5

Emilie Bertilsson, Kristina Schildmeijer + Show 3 more

Open Access

https://doi.org/10.1186/s12910-020-00510-5

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Journal: BMC Medical Ethics	Publication Date: Aug 1, 2020
Citations: 8	License type: open-access

Affiliation: Linnaeus University, Landstinget i Kalmar län

Abstract

BackgroundTo characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation (CPR) and to describe patient involvement in, documentation of, and compliance with decisions on resuscitation (Do-not-attempt-to-resuscitate orders; DNAR).MethodsAll patients who died in Kalmar County Hospital during January 1, 2016 until December 31, 2016 were included. All information from the patients’ electronic chart was analysed.ResultsOf 660 patients (mean age 77.7 ± 12.1 years; range 21–101; median 79; 321 (48.6%) female), 30 (4.5%) were pronounced dead in the emergency department after out-of-hospital CPR. Of the remaining 630 patients a DNAR order had been documented in 558 patients (88.6%). Seventy had no DNAR order and 2 an explicit order to do CPR. In 43 of these 70 patients CPR was unsuccessfully attempted while the remaining 27 patients died without attempting CPR. In 2 of 558 (0.36%) patients CPR was attempted despite a DNAR order in place. In 412 patients (73.8%) the DNAR order had not been discussed with neither patient nor family/friends. Moreover, in 75 cases (13.4%) neither patient nor family/friends were even informed about the decision on code status.ConclusionsIn general, a large percentage of patients in our study had a DNAR order in place (88.6%). However, 27 patients (4.3%) died without CPR attempt or DNAR order. DNAR orders had not been discussed with the patient/surrogate in almost three fourths of the patients. Further work has to be done to elucidate the barriers to discussions of CPR decisions with the patient.

Highlights

To characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation (CPR) and to describe patient involvement in, documentation of, and compliance with decisions on resuscitation (Do-not-attempt-to-resuscitate orders; DNAR)
The place of death of the 630 patients was as follows: 11 (1.7%) in the emergency department (CPR had first been started in the ER after cardiac arrest in the ER), 536 (85.1%) on the ward, 74 (11.7%) in the intensive care unit, 6 (1.0%) in the radiology department and 3 (0.5%) in the operating room
DNAR orders were in place in 43 (58.1%) of the 74 patients who died in the intensive care unit compared to 509 (95%) of the 536 patients who died on the ward

Summary

Introduction

To characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation (CPR) and to describe patient involvement in, documentation of, and compliance with decisions on resuscitation (Do-not-attempt-to-resuscitate orders; DNAR). A large percentage of the population in western countries are dying in hospitals and institutions instead of in their own homes. In Sweden about 40% of all deaths in 2016 occurred in the hospital and almost 40% in institutions for Bertilsson et al BMC Medical Ethics (2020) 21:67 and communication of DNAR orders has repeatedly being reported to be hampered by misunderstandings, possible discrimination issues, cultural differences and inconsistencies [4,5,6,7,8,9,10,11,12,13,14,15]. The DNAR decision should be discussed with the patient or a representative and documented in the patient chart [21, 22]

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