Cardiopulmonary Resuscitation Orders Research Articles

Perceptions and experiences of community-based healthcare professionals in the state of Qatar having do not attempt resuscitation discussions during the COVID-19 pandemic.

The values and attitudes of healthcare professionals influence their handling of "do-not-attempt-resuscitation" (DNAR) orders, as does that of the families they interact with. The aim of this study was to describe attitudes, perceptions, and practices among community-based medical practitioners towards discussing cardiopulmonary resuscitation and DNAR orders with patients and their relatives, and to investigate if the COVID-19 pandemic affected their practice in having these discussions. This is a researcher-developed online survey-based study which aimed to recruit a convenience sample of respondents from a total population of 106 healthcare professionals working for the Mobile Healthcare Service (MHS), Hamad Medical Corporation Ambulance Service in the State of Qatar. 33 family physicians, 38 nurses, and 20 paramedics (n = 91) responded to the questionnaire, of who around 40, 8, and 50%, respectively, had engaged in Do Not Attempt Resuscitation discussions during their work with MHS. 15% of physicians who had experience with Do Not Attempt Resuscitation discussions in Qatar felt that the family or patient were not open to having such discussions. 90% of paramedics thought that Do Not Attempt Resuscitation was a taboo topic for their patients in Qatar, and this view was shared by 75% of physicians and 50% of nurses. Per the responses, the COVID-19 pandemic had not affected the likelihood of most of the physicians or nurses (and 50% of the paramedics) identifying patients with whom having a Do Not Attempt Resuscitation discussion would be clinically appropriate. Overall, for all three groups, the COVID-19 pandemic did not affect the likelihood of identifying patients with whom a Do Not Attempt Resuscitation discussion would be clinically appropriate. We found that the greatest barriers in having Do Not Attempt Resuscitation discussions were perceived to be the religious or cultural beliefs of the patient and/or their family, along with the factor of feeling the staff member did not know the patient or their family well enough. All three groups said they would be more likely to have a conversation about Do Not Attempt Resuscitation if barriers were addressed.

77 Introducing a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) and treatment escalation plan (TEP) guideline in an acute hospital.

Abstract Background In hospital cardiopulmonary resuscitation has a 13–20% survival rate to hospital discharge. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders reduce resuscitation activity in people who are unlikely to survive due to underlying co-morbidities. The project aimed to identify current DNACPR practice and cardiac arrest calls in an acute care hospital and to improve communicating and documentation of DNACPR decisions. Methods A baseline audit of 20 medical charts identified variable practice on documenting DNACPR, inappropriate cardiac arrest calls and poor communication between the multidisciplinary team and patients on DNACPR decisions. A sub-committee of Medical Clinical Governance developed a hospital wide Guideline and Proforma for DNACPR that included a treatment escalation plan (TEP). Using quality improvement methodology and plan-do-study-act cycles the DNACPR proforma and decision support framework was refined and tested. Implementation strategies included stakeholder engagement, education, re-formatting documentation and recruitment of ward champions over a six month period. Post implementation audit measured compliance with completing the proforma and resuscitation calls. Results Clinical audit in February 2023 of 33 patient medical records identified 100% (n = 33) of patients with a DNACPR decision had the correct form in use. 96% documented communication with patients. All proformas were signed by a senior decision maker, included a TEP and were filed correctly in the patients notes. There was a 25% reduction in cardiac arrest calls. Only 56% of proformas were signed by nursing staff. Conclusion Implementing a standardised DNACPR proforma was feasible and improved documentation, visibility and ease of locating DNACPR decisions. It promoted timely communication with patients and families setting realistic goals of care in the TEP. In turn there has been a reduction in cardiac arrest calls. Nurses role in the process remains sub-optimal and there is a need to understand the experience of patients and families.

What's the Harm in Cardiopulmonary Resuscitation?

In clinical ethics, there remains a great deal of uncertainty regarding the appropriateness of attempting cardiopulmonary resuscitation (CPR) for certain patients. Although the issue continues to receive ample attention and various frameworks have been proposed for navigating such cases, most discussions draw heavily on the notion of harm as a central consideration. In the following, I use emerging philosophical literature on the notion of harm to argue that the ambiguities and disagreement about harm create important and oft-overlooked challenges for the ethics of CPR. I begin by elucidating the standard account of harm, called the Counterfactual Comparative Account (CCA). I then show that three challenges to the CCA-preemptive harms, the harm of death, and non-experiential harms-are particularly salient when assessing potential harms for candidates of CPR and likely impact-related decision-making and communication. I extend this argument to explore how the ambiguities of harm might extend to other realms of clinical decision-making, such as the use and limitations of life-sustaining treatments. To address these challenges, I propose two strategies for identifying and minimizing the impact of such uncertainty: first, clinicians and ethicists ought to promote pluralistic conversations that account for different understandings of harm; second, they ought to invoke harm-independent considerations when discussing the ethics of CPR in order to reflect the nuances of such conversations. These strategies, coupled with a richer philosophical understanding of harm, promise to help clinicians and ethicists navigate the prevalent and difficult cases involving patient resuscitation and many other harm-based decisions in the clinical setting.

Changes over time in POLST use and content by race and ethnicity among California nursing home residents.

Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity. California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned. POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups. Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative.

1292P A review of in-hospital end-of-life care (EOLC) for oncology patients during the COVID-19 pandemic

Globally, 40 to 60% of all patient deaths occur in an acute hospital setting. Patients with cancer make up a significant proportion of those who die in hospitals. Clinicians involved in their care should be competent at recognising dying and documenting the quality of EOLC delivered to patients and families. Continued evaluation and audit of the care of the dying patient is essential for quality improvement at an organisational level. The management of patients who died in Cork University Hospital under the Oncology Service’s care between 1 January 2021 and 31 December 2021 was analysed. Paper and electronic records were reviewed, and patient care was assessed using the Oxford Quality Indicators (QIs) for EOLC. Ethical approval was granted by the Cork University Hospital Quality and Patient Safety Department. 66 patients were identified (M:F 29:37). The median age at time of death was 64 years [30-82]. The average length of admission resulting in death was 12.4 days [0-44]. 6% of patients died in the emergency department and 12% of patients died in the intensive care unit. The risk of dying was documented in 95.5% of cases and was communicated to 65.2% of patients and 82.8% of patients’ families. There was a do not attempt cardiopulmonary resuscitation (DNACPR) order in place for 89.4% of patients. Unnecessary investigations and interventions were stopped for 71.2% of patients. Symptom assessment was documented in 81.8% of cases. What was important to the patient was documented as explored in 24.2% of cases. 10.6% of patients were offered a chaplain or faith advisor. The inpatient palliative care team were involved in 77.2% of cases. Using the Oxford QIs for EOLC, the average quality score was 3.5, on a scale of 1-5: 1 (very poor): 0%, 2 (poor): 21.2%, 3 (satisfactory): 33.3%, 4 (good): 19.7%, 5 (excellent): 25.8%. The average EOLC quality score was 3.5. Oncology patients at our centre received, on average, satisfactory-to-good quality EOLC. Shortcomings identified have led to the development of a care of the dying Pro-forma to improve EOLC delivery and a survey of bereaved relatives to identify gaps in care. Holistic care of the dying is a fundamental part of the cancer care spectrum and needs to be prioritised in the acute hospital setting.

The Vicissitude of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order During COVID-19 Pandemic in Japan - A Retrospective Cohort Study.

IntroductionJapan went through five surges of coronavirus disease 2019 (COVID-19) or “waves”. However, their impacts on the do not attempt cardiopulmonary resuscitation (DNACPR) of the patients are not known.MethodsA retrospective single-center cohort study was conducted for all hospitalized patients with COVID-19 from March 1, 2020, to September 30, 2021. Their code status was retrieved, and its association with the waves and other parameters, such as in-hospital mortality, was investigated. The relationship between DNACPR status and each wave was examined, as well as the effect on in-hospital mortality.ResultsA total of 1153 patients were hospitalized with the diagnosis of COVID-19 during the study period. On admission, 117 patients (10.1%) had DNACPR orders, 373 patients (32.4%) were on full code, 45 patients (3.9%) stated that they cannot decide code status. DNACPR rate appeared to increase at the summit of each wave. Subsequently, 160 patients (13.9%) became DNACPR status, 385 patients (33.4%) became full code, and 12 patients (1.0%) stated that they remained unable to decide code status. There was no association between DNACPR status and each wave, and DNACPR status was not associated with higher mortality (P = 0.87), both by logistic regression analysis.ConclusionDNACPR status among hospitalized COVID-19 patients appeared to have changed over multiple waves in Japan, but it is more likely due to the change of the patients’ demographics, particularly their age. DNACPR was common among the elderly, but it was not independently associated with higher mortality.

Do not resuscitate orders in the time of COVID-19: Exploring media representations and implications for public and professional understandings

Context: During the COVID-19 pandemic, the UK press featured headlines that heightened concerns around Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, particularly the use of ‘blanket’ DNACPR orders applied to older people in care settings. The portrayal of DNACPR may impact professional and public understandings with implications for end-of-life care. Objectives: To explore the portrayal of DNACPR orders in the general and academic press and consider implications for public and professional understandings and practice. Method: Academic papers and articles published in the general press during the first wave of the COVID-19 pandemic in the UK were retrieved. Those pertaining to the use of DNACPR orders were analysed thematically. Results: Analysis of 179 media articles and 11 professional commentaries identified mixed understandings of DNACPR as indicated within three themes: rationing of acute services, championing autonomy in DNACPR decisions, and communication and trust. The call to ‘protect the NHS’ marginalised palliative and social care services with DNACPR constructed as a rationing tool. This led to ethical challenges around autonomy, DNACPR decisions, communication and trust. Conclusions: Media coverage of DNACPR orders was contentious and raised questions around the value of life and quality of dying, particularly for vulnerable individuals. DNACPR orders were conflated with frailty, futility and rationing of acute services and the marginalisation of palliative care. Nevertheless, media outputs stimulated advocacy and support for human rights and autonomy. However, it is unclear what the legacy will be for public and professional understandings of advance care planning and the quality of dying.

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

BackgroundWe investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT).MethodsA prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period.ResultsOf 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.ConclusionConsultation 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.

763 QUALITY IMPROVEMENT PROJECT (QIP) ON IMPROVING THE USE OF THE CLINICAL FRAILTY SCALE (CFS) DURING THE COVID-19 PANDEMIC

IntroductionOlder people were disproportionally affected by the COVID-19 pandemic resulting in a surge in the demand for healthcare resources. The aim of this QIP was to assess and improve the compliance of using the CFS in patients over the age of 65 with COVID-19 to aid in establishing appropriate Treatment Escalation Plans (TEPs) during admission.MethodProspectively, clinical notes of 80 patients were reviewed to calculate the compliance of documenting the CFS on admission. Multiple Plan-Do-Study-Act (PDSA) cycles were implemented. As the first intervention, a trust-wide email message was sent to all medical doctors highlighting the importance of assessing CFS in all patients during admission. Also, reminder emails and text messages were sent to all medical doctors’ WhatsApp groups. As the second intervention, we designed an e-poster and displayed it as a screensaver on all trust computers for 2 weeks. Data was collected and analysed after each intervention.ResultsThe baseline audit showed that only 42% of patients had a CFS documented during admission. The majority (55%) had a CFS above 5 and 93% of the patients had a ‘Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order in place. Compliance in assessing CFS after the two interventions was 65% and 68% respectively. In both cycles, all patients who had a CFS of 5 and above had DNACPR decisions in place. Moreover, significant variability in escalation plans was noted when the CFS was 4.ConclusionThe compliance in assessing CFS progressively improved with each intervention. Although the CFS is a valuable tool in assisting TEPs, it should be treated as a spectrum that is independent of age, rather than a binary phenomenon. We hope to further improve compliance by arranging teaching sessions for doctors in our hospital and thereby ensure appropriate TEPs are in place.

Assessment of Physicians' Knowledge of the Management of Sudden Cardiac Arrest

Introduction: Sudden cardiac arrest (SCA) is the abrupt loss of heart function and breathing. It is an absolute medical emergency. The management is based on the principle of the chain of survival. The main objective of this study was to assess the diagnostic and therapeutic abilities of physicians on the care of SCA. Material And Method: It was a multicentre, cross-sectional and descriptive analytical study covering the period from September 01st, 2018 to February 30, 2019. Included were all general practitioners, emergency physicians, cardiologists and anesthetists-resuscitators who agreed to complete the survey. The parameters studied were recognition of signs of SCA and the knowledge about the steps of the chain of survival. Results: We included 78 physicians with an average age of 35,16 years. There were 39 generalists and 39 specialists. The three SCA diagnostic criteria were known to 49 physicians (62.8%). More than half of physicians (n = 54, 69.2%) mastered the chronology of the steps of the chain of survival. The rhythm sequence of chest compressions and insufflations was controlled by 56.4% of physicians (n = 44). About the defibrillation, 70,51% (n=55) responded that it was not systematic in front of any SCA. Thirty-eight physicians were aware of the sequence of adrenaline administration. Only 24 doctors knew the time for amiodarone administration. A minority of 10 physicians has been able to fully define the acronym ABCDE. Conclusion: The level of physicans knowledge on the management of sudden cardiac arrest is relatively average. Every physician must be trained in basic cardiopulmonary resuscitation in order to save lives.

Role of advanced respiratory supportin acute respiratory failure in clinically frail patients with COVID-19.

Background: The main aim of this study was to assess the efficacy of advanced respiratory support (ARS) for acute respiratory failure in do-not-attempt cardiopulmonary resuscitation order (DNACPR) COVID-19 patients. Methods: In this single-center study, the impact of different types of ARS modality, PaO2/FiO2 (PF) ratio, clinical frailty score (CFS) and 4C score on mortality was evaluated. Results: There was no significant difference in age, type of ARS modality, PF ratio and 4C scores between those who died and those who survived. Overall survival rates/hospital discharge of patients still requiring ARS at 5 and 7 days post admission were 20 and 17%, respectively. Conclusion: Our study showed that ARS can be a useful tool in frail, elderly and high-risk COVID-19 patients irrespective of high 4C mortality score.

Palliative medicine in the emergency department: symptom control and aggressive care

ObjectivesIdentifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care.MethodsWe conducted a decedent cohort...

Thinking ahead in advanced illness: Exploring clinicians’ perspectives on discussing resuscitation with patients and families from ethnic minority communities

Evidence suggests that discussing resuscitation with patients and relatives from ethnic minority groups is problematic for healthcare professionals (HCPs), but there is limited evidence exploring these issues or offering guidance for HCPs in navigating these challenging discussions. This study explores the barriers and enablers to HCPs discussing deterioration and resuscitation decisions with patients and families from ethnic minority groups. Personal, cultural, religious/spiritual and health beliefs, emotions, and communication quality and skills were discussed. Participants described that the interaction between these factors as complex, impacting the way some patients and families responded to do not attempt cardiopulmonary resuscitation (DNACPR) orders and the particular challenges these pose. Key barriers and enablers for healthcare professionals discussing resuscitation with patients and families from Black, Asian and minority ethnic communities were identified. The findings highlight areas of improvement for training, both relating to DNACPR discussions and 'cultural competence'.

Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards

The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.

Do-not-attempt-resuscitation orders: attitudes, perceptions and practices of Swedish physicians and nurses

BackgroundThe values and attitudes of healthcare professionals influence their handling of ‘do-not-attempt-resuscitation’ (DNAR) orders. The aim of this study was a) to describe attitudes, perceptions and practices among Swedish physicians and nurses towards discussing cardiopulmonary resuscitation and DNAR orders with patients and their relatives, and b) to investigate if the physicians and nurses were familiar with the national ethical guidelines for cardiopulmonary resuscitation.MethodsThis was a retrospective observational study based on a questionnaire and was conducted at 19 wards in two regional hospitals and one county hospital.Results210 physicians and 312 nurses (n = 522) responded to the questionnaire. Every third (35%) professional had read the guidelines with a lower proportion of physicians (29%) compared to nurses (38%). Around 40% of patients had the opportunity or ability to participate in the DNAR discussion. The DNAR decision was discussed with 38% of patients and the prognosis with 46%. Of the patients who were considered to have the ability to participate in the discussion, 79% did so. The majority (81%) of physicians and nurses believed that patients should always be asked about their preferences before a DNAR decision was made.ConclusionsSwedish healthcare professionals take a patient’s autonomy into account regarding DNAR decisions. Nevertheless, as 50% of patients were considered unable to participate in the DNAR discussion, questions remain about the timing of patient participation and whether more discussions could have been conducted earlier. Given the uncertainty about timing, the majority of patients deemed competent participated in DNAR discussions.

Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients.

Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely.This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.

Knowledge on American Heart Association Guidelines Update for Cardiopulmonary Resuscitation among the Nurses Working at University Hospital, Kavre

Background Cardiopulmonary resuscitation is the foundational technique for the emergency treatment of cardiac arrest and the standardized training of it has been emphasized more than ever. Competence of the nurses in this lifesaving procedure is a critical factor in patient outcome from cardiac arrest and can largely prevent sudden death. Objective Many evidences suggest lack of knowledge on proper cardiopulmonary resuscitation among nurses so the aim of this study was to assess the knowledge on 2015 American Heart Association guidelines update for cardiopulmonary resuscitation among nurses working at University hospital and to identify the relationship between the level of knowledge and selected variables. Method Two hundred and sixty nurses working in Dhulikhel hospital participated in the study. A cross-sectional descriptive study was conducted using a predesigned questionnaire based on 2015 guidelines updates for cardiopulmonary resuscitation that incorporated total of 20 questions. Result Total 260 participated in the study and all were female. Only one third of the nurses had good knowledge regarding 2015 guidelines update for cardiopulmonary resuscitation. No significant results existed between the knowledge score and age of the nurses, duration of work experience. However, significant results existed between the knowledge score and qualification, designation of the nurses and previous training on cardiopulmonary resuscitation. Conclusion One third of the nurses had good knowledge regarding 2015 guidelines update for cardiopulmonary resuscitation in this study. Thus, knowledge and practical approach has to be updated with current guidelines in cardiopulmonary resuscitation in order to improve the safety and effectiveness of patient care.

Limiting treatment in pre-hospital care: A prospective, observational multicentre study.

Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care. A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included. There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n=5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n=133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n=61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n=54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n=153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions. Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.

A global pandemic is not a good time to introduce ‘opt-out’ for organ donation

Following several international examples, England introduced a system of deemed consent for organ donation in May 2020. This had been planned for over a year. However, the unprecedented circumstances of the COVID-19 pandemic raise issues that make the timing of this change unfortunate. The planned public awareness campaign has thus far been overshadowed by media coverage of the pandemic, and will likely continue to be, creating a situation in which a significant portion of the population may be unaware of having become potential organ donors. Further, the immediate impact of the new policy is likely to be significantly weakened by the suspension of the majority of organ donation and transplant activity. In this article, we first outline the details of the new model introduced in England, before considering the impact of the pandemic on transplantation services. We put forward three ethical reasons why, given the unprecedented circumstances, the change should have been postponed. We argue that (1) COVID-19 dominating headlines will prevent widespread awareness of the change, thereby undermining the autonomy of those who do not wish to be donors; (2) a lack of transplant activity during the pandemic will make the impact of the change difficult to measure; and (3) trust in the new system may be damaged given controversial decisions regarding Do Not Attempt Cardiopulmonary Resuscitation orders and the allocation of scarce intensive care resources. These reasons combined make for a shaky start at best and present a risk of the new system failing to achieve its desired and essential effect of increasing the number of voluntary organ donors.

How to verify the death of a patient.

When a patient dies, it is important that nurses understand their role in the verification of death. This article explains the steps required to verify the death of an adult patient. Verification of death is not a mechanistic task, but one that requires sensitivity and compassion. It is also crucial that nurses understand the legal implications of verifying a patient's death. With the development of the current coronavirus disease 2019 (COVID-19) pandemic, nurses must also understand any changes in their role when verifying the death of a patient. Verification or confirmation of death is the process of ascertaining whether a patient is deceased, based on a physical assessment. Nurses can only verify a death if the patient is expected to die and has a do not attempt cardiopulmonary resuscitation (DNACPR) order in place. A DNACPR order is essential because it allows the nurse to verify the death without being concerned withthe need to resuscitate the patient. Nurses should ensure they act in accordance with local and national guidance regarding the verification of a patient's death. REFLECTIVE ACTIVITY: How to articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: How this article might inform your practice when verifying a patient's death. How you could use this information to educate your colleagues on the appropriate steps required when verifying a patient's death.