Attempt Resuscitation Decisions Research Articles

1342 DO NOT ATTEMPT CONVERSATIONS PRE-REHEARSAL: TEACHING MEDICAL STUDENTS TO HAVE DNACPR CONVERSATIONS

Abstract Introduction The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form is widely adopted to document advanced care plans, including Do Not Attempt Resuscitation (DNACPR) decisions. Communication between clinicians and patients, or next of kin is required for completion. It is widely documented UK medical students have little exposure to these experiences, including being asked to leave whilst they are occurring. During the COVID19 pandemic, Foundation Year 1 (FY1) doctors led discussions with increased frequency and autonomy, with no documented concurrent training. We present a novel learning experience designed to aid these discussions. Students were timetabled to a 1.5 hour workshop, facilitated by a clinical teaching fellow. They were invited to complete ReSPECT form for a celebrity to familiarise themselves with the layout. They then considered a patient admission scenario in 3 different groups from the perspective of the patient, family and medical team, and used this to contemplate potential, future, emergency treatments. Subsequently a discussion surrounding CPR effectiveness, ways of communicating this, and legal advanced decision documents occurred. The session concludes with scrutinising example ReSPECT forms provided by the Resuscitation Council UK. Method Students' confidence levels were measured pre and post session using a Likhert scale questionnaire. Results 90 students attended workshops across 6 rotations. 80% students completed post - session questionnaires, of which 100% reported an increase in confidence with having a DNACPR/advanced care planning discussion compared to before the session. Conclusion DNACPR conversations can incite anxiety in any seniority of health care professionals. Medical educators need to adequately prepare medical students during their training in advanced care planning and DNACPR discussions. This can be done with simulated workshop experiences, reinforced with opportunistic or organised observational experience. Adequate preparation will lead to increased confidence in discussions, ultimately leading to better experiences for patients and their families.

National survey of do not attempt resuscitation decisions on out-of-hospital cardiac arrest in China

BackgroundTo investigate and understand the determinants of decisions not to attempt resuscitation following out-of-hospital cardiac arrest, to contribute to establishing rules that are appropriate to China.MethodsWe recruited participants through directors of emergency medical services across China. A 28-question web survey was available between February 5 and March 6, 2021 that targeted demographic information and views on emergency work and cardiopulmonary resuscitation. Each question was assigned a value between 1 and 7 based on the level of importance from low to high. T-tests, one-way analysis of variance, and Kruskal–Wallis H-tests were used to compare continuous variables. Binary logistic regression analysis was used to identify factors influencing when people considered it suitable to initiate cardiopulmonary resuscitation.ResultsThe study involved 4289 participants from 31 provinces, autonomous regions and municipalities in mainland China, of whom 52.8% were male. The top three reasons for not attempting cardiopulmonary resuscitation were decomposition/hypostasis/rigor mortis (6.39 ± 1.44 points), massive injury (4.57 ± 2.08 points) and family members’ preference (4.35 ± 1.98 points). In total, 2761 (64.4%) thought emergency services should not attempt cardiopulmonary resuscitation when cardiac arrest had happened more than 30 min before, and there had been no bystander cardiopulmonary resuscitation. Gender (OR 1.233, p = 0.002), religion (OR 1.147, p = 0.046), level (OR 0.903, p = 0.028) or classification of city (OR 0.920, p = 0.049), years of work experience (OR 0.884, p = 0.004), and major (OR 1.032, p = 0.044) all influenced how long after cardiac arrest was considered suitable for initiating cardiopulmonary resuscitation.ConclusionsChinese emergency physicians have different perceptions of when not to attempt resuscitation to those practicing elsewhere. The existing guidelines for resuscitation are not suitable for China, and China-specific guidelines need to be established.

Outcomes of Continuous Positive Airway Pressure in the Management of Patients with Coronavirus (COVID-19) Pneumonia who are not Suitable for Invasive Ventilation.

Background:The optimum management of respiratory failure in patients with coronavirus (COVID-19) infections has been a challenge for physicians across the globe. Many scientific societies have suggested the use of CPAP (continuous positive airway pressure) in severe cases in an effort to reduce invasive ventilation. We investigated mortality outcomes in patients who needed CPAP but were not suitable for invasive ventilation.Methods:We retrospectively evaluated the mortality outcomes of all consecutive COVID-19 cases with severe type 1 respiratory failure requiring FiO2 >0.6 who were admitted to our hospital between 12th March and 04th May’20. British Thoracic Society guidelines were followed for identifying patients needing CPAP. Their outcomes were recorded and compared with a similar group of patients who had oxygen as a ceiling of care. Prospectively collected data between 5th May and 7th June’20 in similar but smaller groups of patients was also analyzed.Results:A total of 104 COVID-19 patients with documented Do Not Attempt Resuscitation (DNAR) decision required high fraction of inspired oxygen (FiO2) >0.6(to maintain peripheral oxygen saturation (SpO2)> 92%(SpO2> 88% in COPD patients). Twenty-four patients received CPAP as the ceiling of care, with a mortality rate of 92.5%. The remaining 84 patients who were on oxygen as a ceiling of treatment had 91.7% mortality. Both population groups had a similar number of comorbidities but were less favorable in terms of age in the control group with standard O2 therapy than those who had CPAP support. Overall mortality outcomes from using CPAP therapy did not bring significant mortality benefit (p-value-0.89).Conclusion:CPAP did not appear to improve the survival of patients with severe respiratory failure due to COVID-19 related pneumonia and were not suitable for invasive ventilation. Further studies are warranted to adequately inform appropriate management strategies for this group of patients.

Do not attempt resuscitation decisions during the COVID-19 pandemic.

Emeritus Professor Alan Glasper, from the University of Southampton, discusses concerns raised by the Care Quality Commission about the imposition of do not resuscitate orders on some patients during the pandemic.

80 Improving Documentation of DNAR Decisions on the Acute Medical Take

Abstract Introduction The BMA, Resuscitation Council and Royal College of Nursing have set out clear guidelines on documentation of Resuscitation discussions and decisions.1 On the acute medical take documentation of these discussions and decisions can be unclear despite use of an electronic patient record (EPR). The aim of this audit was to improve documentation of Do Not Attempt Resuscitation (DNAR) decisions in EPR. Methods We listed patients admitted on the medical take over 1-week, looking at resuscitation status and the documentation of the DNAR decision. We then implemented a change to the format of the EPR treatment escalation plan (TEP) form. Prior to the change the DNAR form was behind the TEP form which had to be clicked on separately and was not mandatory to complete. After the intervention the DNAR decision was placed in a box on the front page of the TEP form to ensure that it was clear and accessible. Results Pre-intervention we reviewed 114 patients notes of which 94 were DNAR. Of these 94 only 17 (18%) had correctly documented DNAR decisions in EPR. Following the intervention we again looked at all admissions to the medical take over a 1-week period, out of 151 patients 75 were DNAR and of these 75 patients 29 had correctly documented DNAR forms. This shows an increase in the percentage of the DNAR decisions filled in from 18% to 39%. Conclusion The results show that although there has been an improvement in the number of DNAR decisions being documented there are still a large percentage of patients who do not have this correctly documented. We are designing further interventions to ensure that the DNAR documentation is marked as a mandatory part of the TEP form as well as educating around the importance of this documentation.

Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians.

To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE). Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019.

Nurses and guideline for interrupting or not initiating CPR: An exploratory survey

Objective: An area that still causes difficulties and a sense of inadequacy in healthcare providers is related to Do Not Attempt Resuscitation decision (DNAR). The aim of the study is to investigate knowledge, opinions and behaviors of nurses about DNAR in order to plan appropriate improvement interventions.Methods: An anonymous questionnaire was administered to 207 nurses belonging to four Medicine Departments and to four Intensive Care areas. The questionnaire, which consists of 29 items, collects some information related to work experience and investigates opinions and behaviors of nurses about DNAR decision.Results: 55% of the nurses in the sample say they do not know the meaning of the acronym DNAR. It was noted a statistically significant association both between training and knowledge of DNAR (p-value = .038) and between years of work and knowledge of the acronym (p-value = .004). There was also a statistically significant difference between knowledge of the acronym and some opinions and behaviors of nurses, including the importance of informing the patient about DNAR decision (p-value = .028).Conclusions: The study shows that the sample investigated, regardless of the work area of afference, does not know DNAR decision adequately. The lack of knowledge influences opinions and attitudes of nurses in relation to DNAR decision, constituting a barrier for an appropriate management of the patient. The need for more training on the topic and the formulation of clear protocols on DNAR decision emerges.

Reducing DNACPR complaints to zero: designing and implementing a treatment escalation plan using quality improvement methodology

IntroductionDo Not Attempt Resuscitation (DNAR)decisions have traditionally formed the basis of ceiling of care discussions. However, poor quality discussions can lead to high patient and relative dissatisfaction, generating hospital complaints....

Characteristics of patients who are not resuscitated in out of hospital cardiac arrests and opportunities to improve community response to cardiac arrest

AimThis study explores why resuscitation is withheld when emergency medical staff arrive at the scene of a cardiac arrest and identifies modifiable factors associated with this decision. MethodsThis is a secondary analysis of unselected patients who sustained an out of hospital cardiac arrest attended by ambulance vehicles participating in a randomized controlled trial of a mechanical chest compression device (PARAMEDIC trial). Patients were categorized as ‘non-resuscitation’ patients if there was a do-not-attempt-cardiopulmonary-resuscitation (DNACPR) order, signs unequivocally associated with death or resuscitation was deemed futile (15min had elapsed since collapse with no bystander-CPR and asystole recorded on EMS arrival). ResultsEmergency Medical Services attended 11,451 cardiac arrests. Resuscitation was attempted or continued by Emergency Medical Service staff in 4805 (42%) of cases. Resuscitation was withheld in 6646 cases (58%). 711 (6.2%) had a do not attempt resuscitation decision, 4439 (38.8%) had signs unequivocally associated with death and in 1496 cases (13.1%) CPR was considered futile. Those where resuscitation was withheld due to futility were characterised by low bystander CPR rates (7.2%) and by being female. ConclusionsResuscitation was withheld by ambulance staff in over one in ten (13.1%) victims of out of hospital cardiac arrest on the basis of futility. These cases were associated with a very low rate of bystander CPR. Future studies should explore strengthening the ‘Chain of Survival’ to increase the community bystander CPR response and evaluate the effect on the numbers of survivors from out of hospital cardiac arrest.

In what circumstances will a neonatologist decide a patient is not a resuscitation candidate?

ObjectiveThe purpose of this study was to determine the opinions of practising neonatologists regarding the ethical permissibility of unilateral Do Not Attempt Resuscitation (DNAR) decisions in the neonatal intensive care...

Do Not Attempt Resuscitation decision should be attempted in order to reduce the number of futile cardiopulmonary resuscitation

Do Not Attempt Resuscitation decision should be attempted in order to reduce the number of futile cardiopulmonary resuscitation

A reply

We thank Dr Hogan for his letter in which he contends that a ‘confusing re-definition of cardiopulmonary resuscitation (CPR)’ was used in the ‘Do Not Attempt Resuscitation Decisions in the Perioperative Period’ guidelines [1] and in our reply to the letter by Poplett et al. [2]. The definition given in the guidelines is as follows: ‘CPR is undertaken in an attempt to restore breathing and spontaneous circulation in a patient in cardiac and/or respiratory arrest’. This definition is taken verbatim from the joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing on Decisions Relating to Cardiopulmonary Resuscitation published in 2007 (page 6, paragraph 3) [3]. This joint statement was widely referenced in the guidelines. Dr Hogan did not provide any references for his ‘multiple sources’ in which it is ‘generally understood’ that CPR only refers to ‘emergency treatment of cardiac arrest’. However, definitions must not replace the central issue which remains the wish of the patient or proxy decision makers involved in the decision making process with the anaesthetist and surgeon. In the guidelines we sought, where possible, to avoid subjective interpretation of legal and ethical issues and to provide clarity in a situation that is certainly not simple. We attempted to provide options for doctors and patients so that agreement may be reached on how to manage DNAR decisions in the peri-operative period. If agreement cannot be reached the guidelines contain guidance on how this conflict should be resolved. We refute Dr Hogan’s allegation that we have introduced ‘a substantial re-definition of an established medical term’ either in the guidelines or in our reply to Poplett et al. [2]. No external funding and no competing interests declared.

Do not attempt resuscitation decisions in the peri‐operative period

Do not attempt resuscitation decisions in the peri‐operative period

Do Not Attempt Resuscitation decisions in the peri‐operative period

Do Not Attempt Resuscitation decisions in the peri‐operative period

Resuscitation: turning guidelines into practice

PurposeThe purpose of this article is to assess important recent guidelines on resuscitation, published in December 2005.Design/methodology/approachThe guidelines are put into the context of other attempts to standardise CPR practice. An analysis of recent claims and complaints handled by the Medical Protection Society and problems reported to the National Patient Safety Agency, broadens the discussion.FindingsA number of issues of concern arose – the competence of health professionals, recognising the deterioration of patients, communication of Do Not Attempt Resuscitation decisions, and equipment failings. Strengthening training, better monitoring and performance management are important in addressing these issues.Practical implicationsHealth professionals have a good opportunity to avail themselves of the new CPR guidelines; it is in the public interest to try and achieve these standards.Originality/valueThe paper highlights the continuing risks in providing substandard resuscitation.

Making do not attempt resuscitation decisions: do doctors follow the guidelines?

When do not attempt resuscitation orders are contemplated, guidelines exist to outline standards for planning patient care and decision making. These guidelines may not always be fully followed as ethical issues arise which may prevent doctors from doing so.

Do not attempt resuscitation decisions: the nursing role.

This exploratory study examines the roles of practice nurses with regard to do not attempt resuscitation (DNAR) decisions. The British Medical Association (BMA) and the Royal College of Nursing (RCN) have published joint DNAR guidelines. One NHS trust responded by developing a local DNAR policy written for use in hospital and general practice. The study focuses on aspects of compliance with the policy and hence DNAR decision-making, in particular, the nurse's involvement in the decision-making process. The response rate to self-administered questionnaires to practice nurses was 52% (n = 45). Hospital nurses (n = 49) were selected for interview using a quota-sampling technique. Comparisons were made of the views of acute and community staff in their use of the DNAR policy. A clear finding is that hospital nurses wish for more autonomy in DNAR decision-making and improved methods of communicating with medical colleagues when decisions are made. Practice nurses are currently not involved in DNAR decisions. The appropriateness of developing policies for such complex issues as DNAR, when compliance remains low, questions their validity. This study raises awareness, and adds to the discussion for the need for a multidisciplinary approach to DNAR policy.

Where now with Do Not Attempt Resuscitation decisions?

Geriatricians are often asked to make decisions about withholding cardiopulmonary resuscitation. This seems to be becoming more difficult and more controversial. There has been increased public concern about this subject recently and a recognition within the profession of the need for more openness and transparency in decision making. The implementation of The Human Rights Act led to updated guidelines from professional bodies, but these are likely to need careful interpretation in light of local circumstances before they can become a practical tool for decision making.

Do not attempt resuscitation decisions in a cancer centre: addressing difficult ethical and communication issues

Do not attempt resuscitation decisions in a cancer centre: addressing difficult ethical and communication issues

Do not attempt resuscitation decisions in a cancer centre: addressing difficult ethical and communication issues

Do not attempt resuscitation decisions in a cancer centre: addressing difficult ethical and communication issues