Do Not Attempt Resuscitation Decisions Research Articles

Early do-not-attempt resuscitation orders and neurological outcomes in older out-of-hospital cardiac arrest patient: A multicenter observational study.

To explore the association between Do-Not-Attempt Resuscitation (DNAR) orders issued within 6 h of admission and neurological outcomes in older patients with out-of-hospital cardiac arrest (OHCA). Patients aged ≥65 years who experienced OHCA between September 2019 and March 2021 enrolled in the multicenter observational study in Japan (SOS-KANTO 2017) were included. Data regarding DNAR decisions were prospectively collected and the time required to obtain DNAR orders. Patients who received DNAR orders within 6 h of admission (DNAR group) were compared with those who did not (non-DNAR group) using propensity score analysis with inverse probability treatment weighting (IPTW) to adjust for potential confounders. Of the 9909 registered individuals in the SOS-KANTO 2017 study across 42 facilities, 685 were selected for analysis, with 361 (52.7%) in the DNAR group. Even after adjusting for the confounding factors, the frequency of post-admission therapeutic interventions was lower, and the proportion of patients with favorable neurological outcomes was significantly lower (2.6% vs. 19.3%, p < 0.001) in the DNAR group. Twenty-six (7.3%) patients in the DNAR group survived for 1 month, of whom six (1.7%) had favorable neurological outcomes. Older patients with OHCA who had early DNAR had significantly fewer therapeutic interventions after admission and had worse neurological outcomes at 30 days than those without a DNAR order, even after adjusting for demographic and prehospital variables.

Problems Experienced by Health Care Professionals with Do not Attempt Resuscitation (DNAR) Orders - A Qualitative Study.

A 'Do Not Attempt Resuscitation' (DNAR) order is one of the most important yet difficult medical decisions. Despite the recent European guidelines, health care professionals (HCPs) in general perceive challenges in making a DNAR order. We aimed to evaluate the types of problems related to DNAR order making. A link to a web-based multiple-choice questionnaire including open-ended questions was sent by e-mail to all physicians and nurses working in the Tampere University Hospital special responsibility area covering a catchment area of 900,000 Finns. The questionnaire covered issues on DNAR order making, its meaning and documentation. Here we report the analysis of the open-ended questions, examined based on the Ottawa Decision Support Framework with expanded individual decisional needs categories. Qualitative data describing respondents' opinions (N=648) regarding problems related to DNAR order decision making were analysed using Atlas.ti 23.12 software. In total, 599 statements (phrases) dealing with inadequate advice, information, emotional support, and instrumental help were identified. Our results show that HCPs experience lack of support in DNAR decision making on multiple levels. Digital decision-making support integrated into electronic patient records (EPR) to assure timely and clearly visible DNAR orders could be beneficial.

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.

DNAR decisions in Pakistan, Middle East and UK: An emergency physician's perspective

Although resuscitation aims to preserve life and restore health, it is sometimes at the expense of increased suffering and disability to the receiving patient. In this situation, the treating physicians often end up in the dilemma of whether resuscitation is appropriate for the patient and have discussions with the patient and/or family. This may lead to a decision to “Do Not Attempt Resuscitation” (DNAR). In western societies, the patients have an option to opt out of Cardiopulmonary Resuscitation (CPR) if they are in the situation, and at times, the medical team can make a clinical decision when the efforts are deemed futile. This is supported in the legislation of those countries, and as an example, the UK law states, There is no obligation to give treatment that is futile or burdensome.1 As the preservation of life in Muslim countries is of paramount importance due to religious reasons as well as cultures and traditions, a similar blanket approach to DNAR in Muslim countries is rarely seen. One of the earliest Fatwa (Islamic law) on this topic by Shaykh ‘Abd al-‘Azeez ibn ‘Abd-Allaah ibn Baaz and Shaykh ‘Abd al-Razzaaq ‘Afeefi in the year 1986, states “if reviving the heart and lungs is of no benefit and not appropriate because of a certain situation, according to the opinion of three trustworthy specialist doctors, then there is no need to use resuscitation equipment, and no attention should be paid to the opinions of the patient’s next of kin concerning the use of resuscitation equipment or otherwise, because this is not their specialty.” 2 This has led to physicians in Saudi Arabia being empowered to make DNAR decisions for their terminal patients and allow dignified death. The lack of similar legislation in Pakistan often places physicians in the unenviable situation of having to explain to patients and their families why CPR would be futile, and, in the absence of consensus, having to provide expensive, futile treatment, at the expense of the family, and other patients who may benefit from the resources used up. When possible, these discussions should be had by the treating speciality and the patient/families, but emergency physicians often find themselves in the awkward and undesirable situation of initiating these difficult conversations. The area to discuss and investigate here is about the ethical, religious, and legal implications of such a decision, and how an emergency physician can continue to act in the patient’s best interest while keeping themselves safe.

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...

Implementation of a ‘Unified Do Not Attempt Cardio-Pulmonary Resuscitation Order’ – Have we improved communication?

Introduction: In the prehospital setting it is really challenging to reach decisions such as do not attempt resuscitation (DNAR), how long to continue the resuscitation effort and when to stop, since everything is progressing in front of the relatives and information about the cardiac arrest (CA) victim is in most of the cases poor. Material and methods: During the time period between 2001 and 2005, all cardiopulmonary resuscitation (CPR) attempts performed by the crew of the National Prehospital Care System (EKAB) were recorded according to the Utstein Style in the area of Thessaloniki. In total, 1754 CA victims were included in the study, 1349♂ and 405♀, with a mean age of 60.6±14.5 years. Results: In 1237 (70.5%) cases CA happened at home and in 1557 (88.76%) cases CA was of cardiac etiology. Resuscitation was attempted in 1489 (84.89%) cases, whereas in 265 (15.1%) cases a DNAR decision was made. Return of spontaneous circulation (ROSC) was achieved in 602 (40.42%) cases, CPR efforts were terminated in 710 (47.68%) cases and 177 (11.88%) CA victims were transported to thehospitalwith ongoingCPR.Meandurationof CPR was 42.2±15min. Criteria for DNAR were prolonged period until EKAB arrival without bystander CPR and end stage disease (generalized malignancy). Resuscitation attempts were terminated after 30min of CPR without any ROSC. None of the patients, who were transported to the hospital with ongoing CPR, survived. Decision to continue CPR during patient transport, in most of the cases, was not based on specific and objective criteria but on fear or denial of some physicians towithdrawCPR and to inform relatives. In all CAs which occurred at home, CPR was performed in front of the relatives, who were informed at the beginning, during and at the end of the resuscitation attempt accordingly. Conclusion: Our study results suggest that despite all of the difficulties and challenges in prehospital resuscitation, DNAR decisions can be made without problems. Moreover, transport of CA victims with ongoing CPR should be based on concrete criteria, otherwise it seems to be futile.

DNAR: Discuss not attempting resuscitation

The June 2014 United Kingdom court judgement Tracey v Cambridge University Hospital & Others established an obligation to discuss DNAR (Do Not Attempt Resuscitation) orders with patients. Not discussing a DNAR decision was found to be a violation of Article 8 of the European Convention on Human Rights. 1 Tracey v Cambridge University Hospitals NHS Foundation Trust and Others EWCA Civ 822. 2014: 27 Google Scholar Anecdotal evidence in our hospital suggested we are not discussing DNAR orders with all patients particularly those with dementia.

Prolonged non-survival in PICU: does a do-not-attempt-resuscitation order matter

BackgroundEtiologies of pediatric intensive care unit (PICU) mortality are diverse. This study aimed to investigate the pattern of PICU mortality in a regional trauma center, and explore factors associated with prolonged non-survival.MethodsDemographic data of all PICU deaths in a regional trauma center were analyzed. Factors associated with prolonged nonsurvival (length of stay) were investigated with univariate log rank and multivariate Cox-Regression forward stepwise tests.ResultsThere were 88 deaths (males 61%; infants 23%) over 10 years (median PICU stay = 3.5 days, interquartile range: 1 and 11 days). The mean annual mortality rate of PICU admissions was 5.8%. Septicemia with gram positive, gram negative and fungal pathogens were present in 13 (16%), 13 (16%) and 4 (5%) of these patients, respectively. Viruses were isolated in 25 patients (28%). Ninety percent of these 88 patients were ventilated, 75% required inotropes, 92% received broad spectrum antibiotic coverage, 32% received systemic corticosteroids, 56% required blood transfusion and 39% received anticonvulsants. Thirty nine patients (44%) had a DNAR (Do-Not-Attempt-Resuscitation) order with their deaths at the PICU. Comparing with non-trauma category, trauma patients had higher mortality score, no premorbid disease, suffered asystole preceding PICU admission and subsequent brain death. Oncologic conditions were the most prevalent diagnosis in the non-trauma category. There was no gunshot or asthma death in this series. Prolonged non-survival was significantly associated with DNAR, fungal infections, and mechanical ventilation but negatively associated with bacteremia.ConclusionsDeath in the PICU is a heterogeneous event that involves infants and children. Resuscitation was not attempted at the time of their deaths in nearly half of the patients in honor of parents’ wishes. Parents often make DNAR decision when medical futility becomes evident. They could be reassured that DNAR did not mean “abandoning” care. Instead, DNAR patients had prolonged PICU stay and received the same level of PICU supports as patients who did not respond to cardiopulmonary resuscitation.

Adherance to do not attempt resuscitation (DNAR) policy in an irish long stay unit

Background.– There is no legislation in Ireland regarding do not attempt resuscitation(DNAR) orders. The British Geriatric Society(BGS) has guidelines that can direct physicians. Our aim was to look at our institution’s policy, how it correlates to the BGS guidelines and our adherence to it. Methodology.– The policy of our institution was reviewed. Documentation of DNAR orders in a 100-bed nursing unit was reviewed over a 24hour period. Results.– Our policy adheres to the BGS guidelines. Sixty-four percent (n=64) of residentswere female.Median agewas 84 (SD 6.64). Dementia was documented present in 70% (n=70). Admissions were from hospital (77%), another long stay institution (19%) and home (4%). Median length of stay(LOS) was 437 days. 82% (n=82) had DNAR orders with 92.68% (n=74) documented in their medical note. 7.32% (n=6) were reported to have DNAR decisions but documentation was not found due to inaccesible notes. Of the 76 documented, two were in closed files. Of those remaining documentationof capacity, reason forDNARanddocumenteddiscussion with family were present in 21.62% (n=16), 44.59% (n=33), 50.7% (n=39) respectively. It was most commonly discussed with the patient’s offspring(43.59%, n=17). It was documented discussed with 9.91% (n=5) of patients. No significant difference in resuscitation status with regard to LOS (P=0.68), gender (P=0.778), or residence before admission (P=0.906)was seen. DNARorderswere significantly associated with older age(84 vrs 79, P=0.048) and documented dementia (74.39% vrs 50%, P=0.04). Conclusions.– Our adherence to documentation of DNAR orders is suboptimal. Poor documentation does not indicate a lack of appropriate decisions. We aim to achieve 100% compliance through education and introduction of a DNAR proforma.

Outcomes of oesophageal stenting for palliation in elderly patients with oesophageal malignancy

Background.– There is no legislation in Ireland regarding do not attempt resuscitation(DNAR) orders. The British Geriatric Society(BGS) has guidelines that can direct physicians. Our aim was to look at our institution’s policy, how it correlates to the BGS guidelines and our adherence to it. Methodology.– The policy of our institution was reviewed. Documentation of DNAR orders in a 100-bed nursing unit was reviewed over a 24hour period. Results.– Our policy adheres to the BGS guidelines. Sixty-four percent (n=64) of residentswere female.Median agewas 84 (SD 6.64). Dementia was documented present in 70% (n=70). Admissions were from hospital (77%), another long stay institution (19%) and home (4%). Median length of stay(LOS) was 437 days. 82% (n=82) had DNAR orders with 92.68% (n=74) documented in their medical note. 7.32% (n=6) were reported to have DNAR decisions but documentation was not found due to inaccesible notes. Of the 76 documented, two were in closed files. Of those remaining documentationof capacity, reason forDNARanddocumenteddiscussion with family were present in 21.62% (n=16), 44.59% (n=33), 50.7% (n=39) respectively. It was most commonly discussed with the patient’s offspring(43.59%, n=17). It was documented discussed with 9.91% (n=5) of patients. No significant difference in resuscitation status with regard to LOS (P=0.68), gender (P=0.778), or residence before admission (P=0.906)was seen. DNARorderswere significantly associated with older age(84 vrs 79, P=0.048) and documented dementia (74.39% vrs 50%, P=0.04). Conclusions.– Our adherence to documentation of DNAR orders is suboptimal. Poor documentation does not indicate a lack of appropriate decisions. We aim to achieve 100% compliance through education and introduction of a DNAR proforma.

Nurses’ attitudes towards Do Not Attempt Resuscitation orders

Introduction: Do Not Attempt Resuscitation (DNAR) orders represent a difficult and challenging area of practice for many health professionals. Many studies have examined the perspective of physicians, but recent changes have enhanced the role of nurses in the UK. Despite this, there remains a knowledge gap regarding their interactions with DNAR orders. Aim: To explore the opinions and experiences of nursing staff on DNAR orders. Methods: We surveyed nursing staff in a major teaching hospital using a structured tool. Results: 251 nurses were invited to participate in the study. 178 completed forms were received (response rate 70.9%). One third of respondents reported the presence of a resuscitation policy on their ward, although no official policy existed in the hospital. 91% of nurses would resuscitate by default if no decision on DNAR had been made. Most believed that consultants or patients should make decisions, and felt it was the role of the physician to inform the patient. 70% stated that DNAR orders were only clear “sometimes”; and 15% that physicians never discuss them with nurses. 52% said that all hospital patients should be routinely asked if they would like to be resuscitated. 35% have disagreed with a DNAR decision. Nurses overestimated the mean survival rate at cardiac arrests to be 34%. 76% believe they need more training. Conclusion: There is considerable interest in DNAR orders among nursing staff. There was dissatisfaction with regard to how DNAR orders work, including a perceived lack of communication from physicians and lack of clarity in the orders. There is a need for further education and cooperation in this area.

P233 Death and the Respiratory Physician: Challenges to Providing Optimal End-Of-Life Care by Generalists

BackgroundSurveys show most patients want to die at home. However 53% of all UK deaths occur in hospital. Patients with chronic respiratory disease are more likely to die in hospital...

Do not attempt resuscitation: the importance of consensual decisions

To describe the involvement and input of physicians and nurses in cardiopulmonary resuscitation (CPR / do not attempt resuscitation (DNAR) decisions; to analyse decision patterns; and understand the practical implications. A Qualitative Grounded Theory study using one-time open-ended interviews with 40 volunteer physicians and 52 nurses drawn from acute care wards with mixes of heterogeneous cases in seven different hospitals in German-speaking Switzerland. Establishing DNAR orders in the best interests of patients was described as a challenging task requiring the leadership of senior physicians and nurses. Implicit decisions in favour of CPR predominated at the beginning of hospitalisation; depending on the context, they were relieved/superseded by explicit DNAR decisions. Explicit decisions were the result of hierarchical medical expertise, of multilateral interdisciplinary expertise, of patient autonomy and/or of negotiated patient autonomy. Each type of decision, implicit or explicit, potentially represented a team consensus. Non-consensual decisions were prone to precipitate personal or team conflicts, and, occasionally, led to non-compliance. Establishing DNAR orders is a demanding task. Reaching a consensus is of crucial importance in guaranteeing teamwork and good patient care. Communication and negotiation skills, professional and personal life experience and empathy for patients and colleagues are pivotal. Therefore, leadership by experienced senior physicians and nurses is needed and great efforts should be made with regard to multidisciplinary education.

In-hospital cardiopulmonary resuscitation: Trainees' worst and most memorable experiences

To examine the personal experiences of higher specialist trainees in Geriatric Medicine (GM) with regard to cardiopulmonary resuscitation (CPR) and do not attempt resuscitation (DNAR) decision making. UK. Two hundred and thirty-five higher trainee members of the British Geriatrics Society (BGS) at the Specialist Registrar (SpR) level. Postal questionnaire survey. We distributed a questionnaire examining the various issues around DNAR decision making among the trainee members of the BGS in November 2003. In one of the questions, we asked the participants, 'Briefly describe your worst or most memorable experience of DNAR'. Responses to this question were analysed by thematic schema and are presented. Overall the response rate was 62% (251/408) after second mailing and 235 of these were at SpR grade. One hundred and ninety-eight participants provided an answer to the above question, providing diverse and often detailed accounts, most of which were negative experiences and which appeared to have had a powerful influence on their ongoing clinical practice. The emerging themes demonstrated areas of conflict between trainees and other doctors as well as patients and relatives. SpR grade geriatricians are exposed to extreme and varied experiences of DNAR decision making in the UK. Efforts to improve support and training in this area should embrace the complexity of the subject.

Advance orders to limit therapy in 67 long-term care facilities in Finland.

To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders. Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed. Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders. We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.

Advance orders to limit therapy in 67 long-term care facilities in Finland

<h2>Abstract</h2> <i>Objective:</i> To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders. <i>Materials and methods:</i> Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (<i>n</i>=1989), nursing homes (<i>n</i>=3310), and assisted living (<i>n</i>=355) in 67 LTC facilities in 19 municipalities were assessed. <i>Results:</i> Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (<i>R</i>²=0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (<i>R</i>²=0.11), impaired cognition (<i>R</i>²=0.07), level of LTC (<i>R</i>²=0.05), and diagnoses (<i>R</i>²=0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders. <i>Conclusions:</i> We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.

Pre-printed 'do not attempt resuscitation' forms improve documentation?

Do not-attempt-resuscitate orders are fundamental for allowing patients to die peacefully without inappropriate resuscitation attempts. Once the decision has been made it is imperative to record this information accurately. However, during a related research projected we noted that documentation was poor and we thought that the introduction of a pre-printed Do Not Attempt Resuscitation (DNAR) form would improve the documentation process. Two sets of identical research questions were applied retrospectively, 12-months apart, to notes of adult patients (>18 years) who had died during a hospital admission without under-going a resuscitation attempt. Between the first and the second audit, a new resuscitation policy that incorporated a pre-printed DNAR form was introduced into our hospital. A pre-printed DNAR form improved documentation when measured against; clarity of DNAR order (P=0.05), date decision was made/implementation (P=0.014), presence of clinician's signature (P=0.001), identification of the senior clinician making the decision (P< or =0.001) and justification for the DNAR decision (P< or =0.001). However, the pre-printed form made little improvement in encouraging patient involvement in the DNAR decision-making process (P=0.348). A pre-printed DNAR form can improve documentation significantly but it has little effect in encouraging patient involvement in the decision-making process.

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.

Improving decision-making and documentation relating to do not attempt resuscitation orders

Introduction: Do not attempt resuscitation (DNAR) decision-making and recording in case notes can be poor. We have audited current practices pertaining to DNAR orders in a district hospital before and after the introduction of a standardised order form (SOF). Methodology: DNAR decisions in medical case notes were audited before and after the introduction of a SOF. All aspects of the decision were scrutinised against recommended guidelines (BMA/RCN/RC (UK) London: BMA, 1999). Results: Case notes of 156 patients were examined. A total of 62 (39.7%) had combined case note and SOF documentation (Gp1), while 94 (60.3%) had case note documentation only (Gp2). Some 61/62 (98.4%) of DNAR indications in Gp1 were in accordance with guidelines versus 81/94 (86.2%) in GP2 ( P<0.01) and 50/62 (80.6%) of decisions were reviewed in GP1 versus 36/94 (38.3%) in GP2 ( P<0.001). More decisions were authorised by consultants in GP1 (56/62 (90.3%) vs. 35/94 (37.2%) P<0.001) and had active patient participation (9/62 (14.5%) vs. 1/94 (1.1%) P<0.001) compared with Gp2. Conclusion: Documentation of DNAR decisions in medical case notes is poor. Standardised order forms, based on recommended national guidelines that complement case note entries, improve the process and recording of this sensitive decision.