Do Not Attempt Cardiopulmonary Resuscitation Order Research Articles

Code status orders in hospitalized patients with COVID-19

BackgroundThe COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19. MethodsA cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March–October 2020). ResultsAmong 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80. ConclusionsThere was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.

Predictors of outcomes in emergency department patients with suspected infections and without fulfillment of the sepsis criteria

BackgroundData on patient characteristics and determinants of serious outcomes for acutely admitted patients with infections who do not fulfill the sepsis criteria are sparse. The study aimed to characterize acutely admitted emergency department (ED) patients with infections and a composite outcome of in-hospital mortality or transfer to the intensive care unit without fulfilling the criteria for sepsis and to examine predictors of the composite outcome. MethodsThis was a secondary analysis of data from a prospective observational study of patients with suspected bacterial infection admitted to the ED between October 1, 2017 and March 31, 2018. A National Early Warning Score 2 (NEWS2) ≥ 5 within the first 4 h in the ED was assumed to represent a sepsis-like condition with a high risk for the composite endpoint. Patients who achieved the composite outcome were grouped according to fulfillment of the NEWS2 ≥ 5 criteria. We used logistic regression analysis to estimate the unadjusted and adjusted odds ratio (OR) for the composite endpoint among patients with either NEWS2 < 5 (NEWS2-) or NEWS2 ≥ 5 (NEWS2+). ResultsA total of 2055 patients with a median age of 73 years were included. Of these, 198 (9.6%) achieved the composite endpoint, including 59 (29.8%) NEWS2- and 139 (70.2%) NEWS2+ patients, respectively. Diabetes (OR 2.23;1.23–4.0), a Sequential Organ Failure Assessment (SOFA) score ≥ 2 (OR 2.57;1.37–4.79), and a Do-not-attempt-cardiopulmonary-resuscitation order (DNACPR) on admission (OR 3.70;1.75–7.79) were independent predictive variables for the composite endpoint in NEWS2- patients (goodness-of-fit test P = 0.291; area under the receiver operating characteristic curve for the model (AUROC) = 0.72). The regression model for NEWS2+ patients revealed that a SOFA score ≥ 2 (OR 2.79; 1.59–4.91), hypothermia (OR 2.48;1.30–4.75), and DNACPR order on admission were predictive variables for the composite endpoint (goodness-of-fit test P = 0.62; AUROC for the model = 0.70). ConclusionApproximately one-third of the patients with infections and serious outcomes during hospitalization did not meet the NEWS2 threshold for likely sepsis. Our study identified factors with independent predictive values for the development of serious outcomes that should be tested in future prediction models.

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.

Improving ceiling of care decisions and documentation for oncology patients

Hospitalized medically unwell patients can be at risk of in-hospital cardiac arrest and previous studies have demonstrated poor survival after in-hospital cardiac arrests, even despite cardiopulmonary resuscitation (CPR). The rate of success is even lower in patients with metastatic malignancy. Since CPR remains the standard treatment for in-hospital cardiac arrest patients, a “do not attempt cardiopulmonary resuscitation” order (DNACPR) needs to be in place to avoid inappropriate resuscitations in patients with poor chances of in-hospital cardiac arrest survival. More recently, ceiling of care documents such as a Medical Advance Plan have also been developed to provide clinicians a framework for individualised treatment escalation. In this study, we examined the uptake of both national National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and local guidelines to ensure that all acutely admitted oncology patients at a single centre had a CPR status and a Medical Advance Plan.

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.

Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

ObjectivesTo assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.DesignA retrospective case note review of...

The need for consultation before a DNACPR order is made

Before a do-not-attempt cardiopulmonary resuscitation (DNACPR) notice is placed on file, the notice must be discussed with the patient or their relatives ( Tracey v. Cambridge University Hospitals NHS Foundation Trust and others [2014] ; Winspear v. City Hospitals Sunderland NHS Foundation Trust [2015] ). Failing to do so would be contrary to article 8 of the European Convention of Human Rights ( Council of Europe, 1950 ). In this article, Richard Griffith lays out the steps that cardiac nurses must take to ensure that proper consultation occurs before DNACPR notices are placed on file

Does resuscitation status affect decision making in a deteriorating patient? Results from a randomised vignette study.

Aims and objectivesThe aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options (‘UFTO’: an alternative approach that contextualizes the resuscitation decision within an overall treatment plan) on nurses' decision making about a deteriorating patient.MethodsAn online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no‐form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures.ResultsReported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no‐form groups (P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments (all P < 0.001). There was no difference between the UFTO and no‐form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups.ConclusionThe presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no‐form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care.

Patients' characteristics associated with the decision of “do not attempt cardiopulmonary resuscitation” order in a Swiss hospital

BackgroundAccording to Swiss legislation, do not attempt cardiopulmonary resuscitation (DNACPR) order can be made at any time by patients only, unless the resuscitation is considered as futile, based on the doctors' evaluation. Little is known about how this decision is made, and which are the factors influencing this decision. MethodsObservational, cross-sectional study was conducted between March and May 2013 on 194 patients hospitalized in the general internal medicine ward of a Swiss hospital. The associations between patients' DNACPR orders and gender, age, marital status, nationality, religion, number and type of comorbidities were assessed. Results102 patients (53%) had a DNACPR order: 27% issued by the patient him/herself, 12% by his/her relatives and 61% by the medical team. Patients with a DNACPR order were significantly older: 80.7±10.8 vs. 67.5±15.1years in the “with” and “without” DNACPR order group, respectively, p<0.001. Oncologic disease was associated with a DNACPR order issued by the medical team (37.5% vs. 16.9% in the “with” and “without” DNACPR order group, respectively, p<0.05). Being protestant was associated with a DNACPR order issued by the patient (57.9% vs. 25.9% in the “with” and “without” DNACPR order group, respectively p<0.01). ConclusionsOver half of the patients admitted to a general internal medicine ward had a DNACPR order issued within the first 72h of hospitalization. Older age and oncologic disease were associated with a DNACPR decision by the medical team, while protestant religion was associated with a DNACPR decision by the patient.

Revival of confidence.

When Janet Tracey was taken to hospital after a serious car accident in 2011, a do not attempt cardiopulmonary resuscitation (DNACPR) order was placed on her notes. Ms Tracey had terminal lung cancer, but her family said she was not consulted, and the order was cancelled after they complained. A second order was later put in place, with the agreement of the family, and Ms Tracey died at Addenbrooke’s Hospital in Cambridge two days later, aged 63. This case led to a legal fight that ended when the court of appeal agreed with Ms Tracey’s relatives that her human rights had been violated with the first DNACPR order placed without her consent. The judgement stated that when it came to a decision that would ‘potentially deprive the patient of life-saving treatment, there should be a presumption in favour of patient involvement’. The Tracey family’s experience and the legal case have prompted an update of CPR guidance for healthcare staff. Decisions Relating to CPR, issued by the Resuscitation Council UK, the British Medical Association and the RCN, emphasises the importance of patient and relative involvement in decisions on whether to use DNACPR notices. It stresses that, where possible, decisions about whether to carry out CPR for people approaching end of life should be made in advance. Avoiding discussions about this area denies patients and their families the opportunity to be involved in decisions, and could lead to unwanted or inappropriate steps being taken. Survival rates from the time of cardiorespiratory arrest to being discharged from hospital iS TO CK

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

AimsTo 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. MethodsRetrospective 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. ResultsOf 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. ConclusionsAbout 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.

Preparing for the unavoidable: public and clinician expectations of death

Preparing for the unavoidable: public and clinician expectations of death

Documentation of do not attempt cardiopulmonary resuscitation (DNACPR) orders – do electronic DNACPR order (eDNACPR) forms make a clinical difference over standardised paper DNACPR order (sDNACPR) forms?

DNACPR orders are important in sparing patients from inappropriate resuscitation attempts. Accurate documentation of a DNACPR order is required to ensure the decision is clear and understood by those involved....

Deciding right – the UKs first regional integration of advance care decisions

The need for clear decisions and protocols during emergencies has to be balanced against the need to make decisions that avoid unnecessary or distressing treatment. A regional initiative has the...