Do Not Attempt Cardiopulmonary Resuscitation Research Articles

Do not attempt cardiopulmonary resuscitation decision-making process: scoping review

ObjectivesTo conduct a scoping review to explore the evidence of the process of do not attempt cardiopulmonary resuscitation (DNACPR) decision-making.MethodsWe conducted a systematic search and review of articles from 1...

Intensive care following in-hospital cardiac arrest / periarrest calls—experience from one Scottish hospital

BackgroundIn-hospital cardiac arrest/periarrest is a recognised trigger for consideration of admission to the intensive care unit (ICU). We aimed to investigate the rates of ICU admission following in-hospital cardiac arrest/periarrest, evaluate the outcomes of such patients and assess whether anticipatory care planning had taken place prior to the adult resuscitation team being called.MethodsAnalysis of all referrals to the ICU page-holder within our district general hospital is between 1st November 2018 and 31st May 2019. From this, the frequency of adult resuscitation team calls was determined. Case notes were then reviewed to determine details of the events, patient outcomes and the use of anticipatory care planning tools on wards.ResultsOf the 506 referrals to the ICU page-holder, 141 (27.9%) were adult resuscitation team calls (114 periarrests and 27 cardiac arrests). Twelve patients were excluded due to health records being unavailable. Admission rates to ICU were low — 17.4% for cardiac arrests (4/23 patients), 5.7% (6/106) following periarrest. The primary reason for not admitting to ICU was patients being “too well” at the time of review (78/129 — 60.5%). Prior to adult resuscitation team call, treatment escalation plans had been completed in 27.9% (36/129) with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms present in 15.5% of cases (20/129). Four cardiac arrest calls were made in the presence of a valid DNACPR form, frequently due to a lack of awareness of the patient’s resuscitation status.ConclusionsThis study highlights the significant workload for the ICU page-holder brought about by adult resuscitation team calls. There is a low admission rate from these calls, and, at the time of resuscitation team call, anticipatory planning is frequently either incomplete or poorly communicated. Addressing these issues requires a collaborative approach between ICU and non-ICU physicians and highlights the need for larger studies to develop scoring systems to aid objective admission decision-making.

Family Medicine Residents' Knowledge and Attitudes About End-of-Life Care in Taif City, Saudi Arabia.

Background End-of-life care is essential for individuals with advanced illness and their families, providing comfort, symptom control, and dignity in the final year of life. Additionally, physician competence requires the ability to communicate, make decisions, and create relationships in end-of-life care. This study assesses family physicians' knowledge and attitude regarding end-of-life care in Taif, Saudi Arabia. Methods Thisdescriptive cross-sectional study conducted between October and November 2021 assessed the knowledge and attitudes of 163 family physicians in Taif City, Saudi Arabia, regarding end-of-life care. Using a convenient sampling technique, an adapted and validated questionnaire was administered electronically, collecting sociodemographic information and assessing participants' knowledge and attitudes. Data were analyzed using descriptive statistics in Statistical Product and Service Solutions (SPSS, version 28) (IBM SPSS Statistics for Windows, Armonk, NY). Results Findings included that 41.1% of residents believed the patient and family should be informed about diagnoses and prognoses in advanced diseases. At the same time, attitudes varied, with 45.4% agreeing that discussing such information could lead to patient depression and 42.9% believing it held no privilege for patients. Additionally, 57.7% recognized that grief reactions would occur, but patients would eventually adjust, and 44.8% agreed that discussing diagnoses would decrease patient anxiety. However, limited awareness of advance directives was evident, with 12.3% reporting being well aware and 45.4% having never heard of them. There was uncertainty and hesitancy regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions, with 39.9% being well aware and 46% having heard of it without a strong understanding. Conclusion The findings revealed a mixed landscape, with physicians demonstrating awareness of the importance of transparent communication but needing more knowledge in areas such as advance directives and complex decision-making. The study highlighted the need for targeted education to address these gaps and promote a more informed and consistent approach to end-of-life care.

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.

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.

One death doesn't fit all: how should we approach end-of-life care in very frail adults?

Death is inevitable. When, however, is bound by uncertainty in frailty. A purely proactive approach to dying - exemplified by the DNACPR (do not attempt cardiopulmonary resuscitation) form - is unrealistic. What does a good death look like - and who decides? To understand the experiences of primary care clinicians and bereaved relatives in end-of-life (EOL) care and inform future service provision for frail and dying people. We conducted 21 semi-structured interviews with 12 GPs and 9 relatives of recently deceased patients and completed an inductive thematic analysis. We identified four themes: 1) relationships and duty of care: many participants identified the responsibility - medical and familial - associated with EOL care. Discussions and decision-making around death, while crucial, create a significant emotional burden; 2) power and authority: the decision-making process involves multilayered power dynamics between families, patients, and clinicians in attempts to manage uncertainty. Medical judgements' authority can be simultaneously welcomed and challenged. Advanced care planning can become symbolic of hidden tensions around acceptance of death; 3) conflicting ideologies: conflicting binary ideas around a 'good death' recurred, with no universal preferences. Understanding where families, the dying, and the doctor sit on these spectra is crucial and rarely communicated; 4) resource limitations (for example, lack of social care support) constrain the decision-making process. You only get one chance to die well. Thoughtful and empathetic decision-making in a reactive and complex environment is crucial to supporting patients, loved ones, and clinicians. A one-size-fits-all proactive 'death conveyor belt' is unrealistic.

'That's as hard a decision as you will ever have to make': the experiences of people who discussed Do Not Attempt Cardiopulmonary Resuscitation on behalf of a relative during the COVID-19 pandemic.

COVID-19 brought additional challenges to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision-making, which was already a contentious issue. In the UK, reports of poor DNACPR decision-making and communication emerged in 2020, including from the regulator, the Care Quality Commission. This paper explores the experiences of people who discussed DNACPR with a healthcare professional on behalf of a relative during the coronavirus pandemic, with the aim of identifying areas of good practice and what needs to be improved. a total of 39 people participated in semi-structured interviews via video conferencing software or telephone. Data were evaluated using Framework Analysis. results are presented around three main themes: understanding, communication and impact. Participants' understanding about DNACPR was important, as those with better understanding tended to reflect more positively on their discussions with clinicians. The role of relatives in the decision-making process was a frequent source of misunderstanding. Healthcare professionals' communication skills were important. Where discussions went well, relatives were given clear explanations and the opportunity to ask questions. However many relatives felt that conversations were rushed. DNACPR discussions can have a lasting impact-relatives reported them to be significant moments in care journeys. Many relatives perceived that they were asked to decide whether their relative should receive CPR and described enduring emotional consequences, including guilt. the pandemic has illuminated deficiencies in current practice around DNACPR discussion, which can have difficult to anticipate and lasting negative consequences for relatives. This research raises questions about the current approach to DNACPR decision-making.

Do not attempt cardiopulmonary resuscitation documentation: a quality improvement project

ObjectivesThis quality improvement project looked at enhancing do not attempt cardiopulmonary resuscitation (DNACPR) documentation in a Welsh National Health Service trust.MethodsA full clinical review cycle was carried out, evaluating 50...

A step-by-step guide to DNACPR from the Resuscitation Council UK

Resuscitation Council UK ReSPECT (Recommended summary plan for emergency care and treatment) clinical lead Catherine Baldock and legal adviser for the ReSPECT process Alex Ruck Keene KC (Hon) answer some of the questions most commonly asked about do not attempt cardiopulmonary resuscitation (DNACPR) recommendations.

Preparing for end-of-life: learning from Do Not Attempt Cardiopulmonary Resuscitation decision-making during COVID-19.

During the COVID-19 pandemic, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made differently. This included more prominent roles for specialties such as psychiatry and doctors in training. Concerns about inappropriate DNAR decisions led to anxiety for doctors, patients and the public. Positive outcomes may have included earlier and better-quality end-of life-discussions. However, COVID-19 exposed the need for support, training and guidance in this area for all doctors. It also highlighted the importance of effective public education about advanced care planning.

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.

How is COVID-19 changing the ways doctors make end-of-life decisions?

BackgroundThis research explores how the COVID-19 pandemic has changed the ways doctors make end-of-life decisions, particularly around Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR), treatment escalation and doctors’ views on the...

978 ADVANCED CARE PLANNING IN PATIENTS WITH PARKINSONIAN DISORDERS

Abstract Introduction Advanced care planning (ACP) supports individuals to make decisions regarding their future care. Guidelines (NICE, 2017) recommend offering ACP discussions to people with Parkinson’s Disease (PD), but uptake lags behind other countries (Sokol, NPJ Parkinson’s Dis, 2019, 22:5–24). As part of a project to improve ACP in the community we audited ACP practice at North Bristol NHS Trust. Method Records for 100 patients with idiopathic PD or atypical Parkinsonian syndromes seen in Movement Disorders clinics from March to October 2021 were scrutinised. ACP was defined as including: Do not attempt cardio-pulmonary resuscitation (DNACPR), Advanced Statement of Wishes, Advanced Decision to Refuse Treatment (ADRT) and Lasting Power of Attorney (LPOA). Disease severity was assessed using Hoehn and Yahr (H&amp;Y) score. Results 87 records were audited, 13 were excluded due to non-Parkinsonian disorders (11) or unavailable records (2). ACP was completed for 22 (25%) cases, (18 DNACPR and 11 Advanced Statements, 1 LPA, 0 ADRT). Informal ACP, such as documentation of wishes in clinic letters, were present in 5 cases. Of the 22 instances of ACP, 20 were recorded on Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. Preferences included ventilation (10), hospital admission (6), life prolonging treatments (6), preferred place of care (4), nutrition (0). Completed ACP was associated with higher H&amp;Y scores or atypical syndromes. Conclusion It is recognised that there is a need to further investigate how ACP is delivered for patients with Parkinsonian Disorders. Three US studies estimated ACP rates ranging from 14.6%–53%. (Nimmons, European Journal of Neurology 2020, 27:1971–1987). We are not aware of any comparable UK data. This is a preliminary audit for a project to improve ACP within our MD Service. We are collecting further data on the views of our community movement disorders team with a view to upskilling in ACP.

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.

781 IMPROVING THE QUALITY OF DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION (DNACPR) FORM COMPLETION

Abstract Introduction The completion of a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form represents an important part of patient care. However, this can be a sensitive process that has gained national media interest. The aim of this Quality Improvement (QI) Project was to improve the quality of DNACPR form completion in a Care of the Elderly Department. Methods The QI project ran from May 2019 to January 2021 and was overseen by a multi-disciplinary team (including patient representation). DNACPR forms on the Care of the Elderly wards were audited monthly against 7 standards which correspond to key sections on the DNACPR form. During the data collection process, interventions were implemented using Plan-Do-Study-Act cycles. Interventions included: appointing ‘DNACPR Champions’ to complete monthly audits and provide personalised clinician feedback, the introduction of a new mandatory e-learning module, the creation of an alert system on nerve centre (the Trust’s electronic handover system) and the development of new DNACPR patient information including webpage development, videos and leaflets. Results The project has led to sustained improvements in majority of the 7 standards. The biggest improvements were seen in the inclusion of a review date, correct completion of the mental capacity assessment and the use of patient information leaflets. The documentation of discussions with patient and relatives remained below the audit standards and was largely unchanged during the QI project. Conclusion A multi-disciplinary and multi-faceted QI approach has shown to improve the quality of DNACPR form completion. Further work is needed to continue this process and a focus on staff training and ward-level processes will be the priority.

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.

Implementing advance care plans in the peri-operative period, including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline.

Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.

Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions in patients admitted through the emergency department in a Swedish University Hospital – An observational study of outcome, patient characteristics and changes in DNACPR decisions

AimsThe aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status. MethodsThis was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015. ResultsThe cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration. ConclusionFor a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.