Do Not Attempt Resuscitation Orders Research Articles

Abstract 18146: Deactivation Status of Defibrillation at the End of Life in Patients With Implantable Cardioverter Defibrillators

Background: Implantable cardioverter-defibrillators (ICDs) are effective in preventing sudden cardiac death due to fatal arrhythmias. However, defibrillation is also known to cause physical and emotional distress to the patients. When patients with an ICD are approaching the end of life, the guidelines on palliative care in cardiovascular diseases recommend that the benefits and burdens of ICDs are fully explained to the patients and that a policy regarding the deactivation of defibrillation function is discussed. However, there are few reports on the therapy status of ICD patients in the end-stage of life.Aim: To investigate the deactivation status of defibrillation in patients with an ICD. Methods: We retrospectively analyzed ICD database at our hospital and studied 143 ICD patients who died from 2006 to June 2023. The frequency of ICD therapy delivered before death and information about the discussion of deactivation and do not attempt resuscitation (DNAR) decisions were reviewed using medical charts. Results: Of 143 patients, 45 (31%) patients in the end-stage of life were assigned to DNAR and 24 (17%) patients was explained deactivation of ICD therapies at the time of DNAR order. Fifteen (10%) patients, including 11 patients in the end-stage heart failure, underwent deactivation and 2 patients received ICD therapies after DNAR order. Nine (6.2%) patients did not undergo deactivation. Of those, 4 patients received ICD shock therapies. Twenty-one patients (15%) were not given the explanation for the deactivation after DNAR order. Of those, 4 patients received ICD shock therapies. Conclusion: Our study shows that only 10% of Japanese ICD patients in the end-stage of life underwent deactivation of ICD therapies. Discussions regarding ICD deactivation in palliative care are necessary to reduce the risk of painful shocks and distress during the end of life.

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.

Factors affecting do-not-attempt-resuscitation (DNAR) decisions among adult patients in the emergency department of a general tertiary teaching hospital in China: a retrospective observational study

ObjectiveDo-not-attempt-resuscitation (DNAR) orders are designed to allow patients to opt out of receiving cardiopulmonary resuscitation in the event of a cardiac arrest. While DNAR has become a standard component of...

Predicting the probability of good neurological outcome after in-hospital cardiac arrest based on prearrest factors: validation of the good outcome following attempted resuscitation 2 (GO-FAR 2) score.

The Good Outcome Following Attempted Resuscitation (GO-FAR) 2 score is a prognostic tool developed to support decision-making for do-not-attempt-resuscitation (DNAR) orders by predicting neurological outcomes after in-hospital cardiac arrest (IHCA) based on prearrest variables. However, this scoring system requires further validation. We aimed to validate the GO-FAR 2 score for predicting good neurological outcome in Korean patients with IHCA. A single-centre registry of adult patients with IHCA from 2013 to 2017 was analysed. The primary outcome was discharge with good neurological outcome (Cerebral Performance Category score of 1 or 2). The patients were divided into four categories according to the GO-FAR 2 score: very poor (≥ 5), poor (2-4), average (-3 to 1), and above-average (< -3) likelihood of good neurological outcome. Of 1,011 patients (median age, 65years), 63.1% were men. The rate of good neurological outcome was 16.0%. The proportions of patients categorised as having very poor, poor, average, and above-average probability of good neurological outcome were 3.9%, 18.3%, 70.2%, and 7.6%, respectively. In each category, good neurological outcome was observed in 0%, 1.1%, 16.8%, and 53.2%, respectively. Among patients in below-average categories (very poor + poor, GO-FAR 2 score ≥ 2), only 0.9% had good outcome. GO-FAR 2 score ≥ 2 showed a sensitivity of 98.8% and a negative predictive value of 99.1% in predicting good neurological outcome. The GO-FAR 2 score can predict neurological outcome after IHCA. In particular, GO-FAR 2 score ≥ 2 may support decision-making for DNAR orders.

Change in Code Status Orders of Hospitalized Adults with COVID-19 Throughout the Pandemic: A Retrospective Cohort Study.

Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.

Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia.

Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.

Decision-making ethics in regards to life-sustaining interventions: when physicians refer to what other patients decide

BackgroundHealth decisions occur in a context with omnipresent social influences. Information concerning what other patients decide may present certain interventions as more desirable than others.ObjectivesTo explore how physicians refer to what other people decide in conversations about the relevancy of cardio-pulmonary resuscitation (CPR) or do-not-attempt-resuscitation orders (DNAR).MethodsWe recorded forty-three physician–patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR is discussed. Data was analysed with conversation analysis.ResultsReference to what other people decide in regards to CPR is used five times, through reported speech. The reference is generic, and employed as a resource to deal with trouble encountered with the patient’s preference, either because it is absent or potentially incompatible with the medical recommendation. In our data, it is a way for physicians to present decisional paths and to steer towards the relevancy of DNAR orders (“Patients tell us ‘no futile care’”). By calling out to a sense of membership, it builds towards the patient embracing norms that are associated with a desirable or relevant social group.ConclusionsIntroducing DNAR decisions in terms of what other people opt for is a way for physicians to bring up the eventuality of allowing natural death in a less overt way. Formulating treatment choices in terms of what other people do has implications in terms of supporting autonomous and informed decision making, since it nudges patients towards conformity with what is presented as the most preferable choice on the basis of social norms.

JCS/JHRS 2021 guideline focused update on non-pharmacotherapy of cardiac arrhythmias.

In 2019, the Guidelines for non-pharmacotherapy of cardiac arrhythmias (JCS/JHRS 2019) were published, covering areas such as treatment using cardiac electrical implantable devices (CIEDs), catheter ablation, surgical treatments, and therapies using left atrial appendage occlusion devices.1 According to the recent dramatic development of non-pharmacotherapy in the field of cardiac arrhythmias, major revisions had been made to the JCS/JHRS 2019 guidelines, owing to critical evaluation by many clinicians. Following the publication of the guidelines, however, more, important clinical evidence had been established in both Japan and abroad, and new concepts of treatment have been created. As updating and disseminating new information directly affects daily clinical practice, we decided to publish “The focused updated guidelines on non-pharmacotherapy of cardiac arrhythmias (JCS/JHRS 2021)” focusing on fields with significant progression, instead of waiting for the next revision of the entire guidelines. Our standards for selecting the issues in the focused update guidelines were as follows: (1) therapy with a previously undetermined recommendation level that has become specified because of new evidence from both Japan and abroad, (2) newly established therapeutic concepts, and (3) important issues in which omission in the previous guidelines was inevitable because of word limits. Accordingly, the main features of these focused updated guidelines are as follows. Although a large international clinical trial to test the utility of leadless pacemakers had been published when the previous guidelines were announced, we did not address the recommendation because it had been suggested that the incidence of complications owing to the small body size of Japanese patients might be higher than in Western patients. However, a subanalysis of a large clinical trial based on Japanese data,2 and our subsequent clinical experience, allowed us to describe the recommendation level. The novel anti-heart failure pacing therapy (ie, conduction system pacing [His bundle pacing]) has appeared as a novel but different concept to cardiac resynchronization therapy (CRT). When the previous guidelines were announced, there were no guidelines or expert consensus that clarified the recommended therapeutic level; however, the new ACC/AHA/HRS guidelines in 2019 stated a recommended level,3 and the initial concept of His bundle pacing was extended to conduction system pacing including both His bundle and left bundle pacing. Therefore, based on the present consideration, we describe recommended levels of conduction system pacing. The recently established concept of advance care planning (ACP) has facilitated the process of discussing and making decisions with healthcare patients for their preferred goals of care if they lose their communication ability in the future. When facing the end of life, ICD therapy (especially shock therapy) is not always desired by patients or their families; therefore, the decision to deactivate the ICD therapy can be acceptable. With the overlap in the timing of publishing JCS/JHFS 2021 Statement on Palliative Care in Cardiovascular Diseases,4 we decided to describe the class recommendations based on the evidence level and decision-making process in this focused update. In association with ACP, we also mention the indications for ICDs in elderly patients. The description of several important aspects of transcutaneous lead extraction (ie, bacteremia without lead infection, superficial infection around the subcutaneous pocket, antibiotic therapy, and CIED re-implantations after lead extraction) were excluded in the previous guidelines but are addressed in the focused update. Although large, international clinical trials demonstrating the efficacy of ATP (capabilities to terminate atrial fibrillation [AF] and prevent the aggravation of AF into a persistent type) had been published in other countries when the previous guidelines were announced, we did not address this therapy because of the absence of clinical evidence from Japan and because of word limits. Taking the novel Japanese evidence of ATP for AF with CIEDs5 into account, however, we decided to include ATP in the focused update. The JCS/JHRS 2020 guidelines on pharmacotherapy of cardiac arrhythmias addressed the clinical significance of asymptomatic (silent) AF and advanced methods of documenting AF.6 In response to the guidelines, we prescribe appropriate management of AF detected by CIED monitoring (focusing on anticoagulant therapy especially) in the focused update. The development of 3D mapping systems has largely contributed to identifying the precise position of catheters in the cardiac chambers without fluoroscopic guidance, thereby reducing the exposure to radiation during catheter ablation procedures. Problems due to radiation injury had been mentioned in previous guidelines; however, to promote awareness and knowledge of reducing the radiation exposure of clinicians, we focused on the use of advanced 3D mapping systems to reduce exposure dose. Besides intraoperative radiation exposure, we described unignorable radiation exposure by preprocedural computed tomography (CT) imaging. According to the CABANA study,7 a new large randomized clinical trial that tested the prognostic efficacy of catheter ablation in patients with AF, we reconsidered the class recommendations for catheter ablation of asymptomatic AF. Further, we were able to establish the class recommendations for catheter ablation in AF patients with heart failure based on even higher levels of evidence (ie, a large randomized clinical trial and meta-analysis including several important clinical studies8). Furthermore, the efficacy of early rhythm-control therapy for AF, either with antiarrhythmic drugs or catheter ablation (pulmonary vein isolation using the cryoballoon technique), has been reported by several large randomized clinical trials.9-11 Taking these results into account, we describe the significance of early rhythm-control to prevent deterioration of AF. As for the new technologies of catheter ablation, high-power radiofrequency delivery with a short duration and the expanded use of the cryoballoon technique for persistent AF are addressed. The management of anticoagulation therapy during the peri-catheter ablation period has been rewritten because various important clinical evidence has been documented in both Japan and abroad,12-18 and because a supplemental description was needed according to the contents of the Guidelines on non-pharmacotherapy of cardiac arrhythmias (JCS/JHRS 2019).6 Because percutaneous transcatheter therapies for left atrial appendage occlusion were not reimbursed in Japan when the previous guideline was announced, detailed description of this technology was postponed. However, sufficient clinical experience has since accumulated in both Japan and abroad, to understand the appropriate indications, safety, postoperative management, and long-term efficacy of this therapy.19 Therefore, we describe the class recommendations for this novel technology in the present focused update. This set of guidelines recommends indications for non-pharmacotherapy of arrhythmia based on the latest findings and evidence. We first surveyed materials based on evidence from the USA and Europe, then further critically examined the levels of evidence, collected information available in Japan, and examined all material based on the experiences and opinions of members and collaborators in the Joint Working Group. This revision adds new knowledge acquired from advances in diagnostic techniques and treatment methods, or recently reported important evidence, while considering consistency with each of the previously reported guidelines published by the JCS/JHRS Joint Working Group. The recommendation of classes and evidence levels used in this set of guidelines conform to those of the American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS) guidelines.20 The recommended class of indications for each diagnosis and treatment method is classified as I, IIa, IIb, or III, and the level of evidence is classified as level A, B, or C (Tables 1, 2). The guidelines also state the grade of recommendation and level of evidence based on the “Medical Information Network Distribution Service (MINDS) Handbook for Clinical Practice Guideline Development 2007”,21 published by the MINDS Evidence-based Medicine dissemination promotion project as a guideline preparation method (Tables 3, 4). However, the MINDS Grade of Recommendation and Level of Evidence should be used only as a reference, as this system regards the evidence level in a fundamentally different manner. The MINDS level of evidence (levels of evidence in literature on treatment) is a classification based on research design, and the highest level was adopted when multiple papers were considered. This set of guidelines is designed to be used as a reference by doctors diagnosing and treating diseases in clinical practice, but the final decision should be made by the attending physicians after ascertaining the patient's condition. Even when selecting a diagnosis or treatment that does not follow the guidelines, the decision of the attending physicians should be prioritized in consideration of the individual patient's situation. In actual clinical settings, it is more important for the attending physicians to make the judgment after considering the clinical background and social situation of each patient fully while complying with the guidelines. Although the leadless pacemaker is an emerging pacing technology, the clinically available mode of a leadless pacemaker in Japan, as of January 2021, is VVI; therefore, an appropriate indication should be considered. Symptomatic bradycardic atrial fibrillation (AF) is a Class I indication. Patients with atrioventricular (AV) block without AF or sinus node dysfunction might benefit from the leadless VVI pacemaker only when the risk of implantation of the atrial lead is higher than its benefit, the patient has severe frailty, is bed-ridden, or has less than 1-year survival (Table 5). An investigational device exemption (IDE) study included 36 patients from Japan.2 Albeit a smaller body status, the safety and efficacy endpoints in Japanese patients were comparable to those in patients from the rest of the world. Cardiac perforation occurred in approximately 1%, and 15% of them required surgical repair.2 Given that the risk factors for cardiac perforation include female sex, old age (≥85 years), chronic respiratory disease, body mass index <20 kg/m2, congestive heart failure, and steroid use, a typical candidate for a leadless pacemaker may be high-risk.22, 23 Hence, a careful risk evaluation is important. The leadless pacemaker is MRI conditional (1.5 and 3 T).24 There are no established data on radiation therapy, but a case study reported that up to 30 Gy radiation therapy in a patient with mediastinal malignancy with a leadless pacemaker inside the radiation field yielded no remarkable damage to the pacemaker.25 Nevertheless, it is recommended that electrical parameters should be checked prior to and after radiation therapy or MRI.24, 25 In hemodialysis patients, the leadless pacemaker is often chosen due to the venous occlusion caused by previous hemodialysis catheters, to improve the patency of an arteriovenous fistula, or to minimize the infection rate. In 3 studies of the Micra transcatheter pacing system (IDE, Micra Transcatheter Pacing System Continued Access Study, and Post-Approval Registry), 201 out of 2,819 patients (7%) were under hemodialysis.26 A majority of the patients (72%) had conditions that precluded transvenous pacing, including the need to preserve venous access (79%), prior infection (20%), and venous occlusion (17%). A successful implant was achieved in 98%, and safety and electrical parameters were similar to non-hemodialysis patients. Although an infection rate of 8% has been reported with conventional pacemakers,27 no infection was reported in these patients. Worldwide experience with successful retrieval of the leadless pacemaker has been reported.28 Data from the manufacturer recorded 40 successful retrievals, and operators for 29 successful retrievals provided information. Of the 29 retrievals, 11 were during the index procedure; 18 retrievals were performed after a median of 46 days (1-95 days). Reasons included threshold increment after tether removal (n = 5), loss of capture (n = 3), dislodgement (n = 3) for immediate retrieval, and elevated threshold at follow-up (n = 11), endovascular infection (n = 1), need for transvenous device (n = 2), and CRT upgrade (n = 1) for delayed retrieval. Average time of the retrieval and fluoroscopy was 63.11 min and 16.7 min, respectively, and no adverse events were observed. Of the 1820 patients in the Micra post approval registry, 105 had re-implantation of leadless pacemaker within 30 days after CIED extraction.29 The extracted CIEDs were pacemakers (70.5%), CRT-P (9.5%), and ICD/CRT-D (12.4%), and 93% were complete explants. Pacing-dependent patients underwent a same-day implant more frequently, and non-dependent patients underwent the implant after a median of 7 days; 91% had IV antibiotics pre-implantation, and 42% had them post-implantation as well. During an average of 8.5 months, 2 patients died of sepsis, and 4 patients required a system upgrade, but no leadless pacemaker was explanted due to re-infection. This finding might suggest that a leadless pacemaker is reasonably safe with no recurrent device infection, which may be due to the absence of a subcutaneous pocket, a smaller surface area as compared with the transvenous lead, a greater tendency of encapsulation, and a high-flow environment in the heart cavity. A total of 16 out of 720 patients (2.2%) in the IDE study developed 21 serious cases of bacteremia or endocarditis during follow-up.30 Infection occurred at a mean of 4.8 months after implantation; 13 events were caused by Gram-positive organisms and 3 by Gram-negative bacteria. Two of the three cases of endocarditis resulted in death; one patient with prosthetic aortic valve endocarditis died immediately postoperatively, the other with aortic valve endocarditis 108 days post leadless pacemaker implantation refused surgical intervention. All but 2 patients responded well to antibiotics, and no persistent bacteremia was observed after antibiotic cessation. MicraTM, the clinically available leadless pacemaker in Japan as of January 2021, provides accelerometer-based rate-adaptive pacing. Accelerometer signals identify 4 distinct segments of cardiac activity: isovolumic contraction and mitral/tricuspid valve closure (A1), aortic/pulmonic valve closure (A2), passive ventricular filling (A3), and atrial contraction (A4). Using the downloadable algorithm with accelerometer-based atrial sensing, the MARVEL study showed that AV synchrony improved in patients with complete AV block from 37.5% to 80% compared with VVI mode.31 An improved automated algorithm was evaluated in patients with sinus rhythm with complete AV block in the MARVEL 2 study.32 Median AV synchrony significantly improved in VDD mode compared with VVI mode (27% vs. 94%). AV synchrony ranged from 89.2% during the resting period to 69.8% while standing. The decline in AV synchrony could be due to orthostatic tachycardia or a decrease in the A4 signal because of reduced venous return. Long-lasting right ventricular (RV) pacing produces an iatrogenic desynchronized contraction of the left ventricle (LV), and possibly induces reduced contraction and mechanical remodeling of the LV.33, 34 To resolve this issue of RV pacing, several animal and clinical studies have demonstrated that artificial pacing of the His bundle instead of the RV can provide long-term physiological ventricular conduction.35-37 However, when this concept was initially proposed, permanent and stable His bundle pacing was technically difficult at that time, and therefore, this method was not widely used (Table 6). Recently, however, a newly designed pacing lead and delivery system aimed at pacing the His bundle has emerged and provided >80% success rate,38-43 and the method has been taken up very rapidly since. More recently, this concept has been further developed to enable transseptal left bundle pacing,44 and His bundle and left bundle pacing have become collectively known as “conduction system pacing”. Several clinical studies have demonstrated the efficacy of His bundle pacing for patients with bradycardia (mainly atrio-ventricular block) who have an indication for permanent pacing with a normal or moderately reduced LV ejection fraction (LVEF) (Table 7).38-43 Two randomized clinical trials compared the efficacy of RV pacing to that of His bundle pacing using a crossover design (switching from one pacing method to the other within a fixed period),38, 41 and demonstrated that His bundle pacing improved LVEF. However, the results from the 2 studies were not consistent regarding the improvement in NYHA functional class and 6-min walk distance. Two clinical observational trials, in which the patients were separately assigned to His bundle pacing at a certain hospital and RV pacing at a second hospital, showed an improvement in LVEF39 and reduction in heart failure hospitalizations.42 Furthermore, a meta-analysis accumulating data from many trials revealed LVEF improvement in patients with a preoperative LVEF <50%.43 To date, however, the efficacy of His bundle pacing has not been confirmed by large randomized clinical trials; previous clinical studies were small-scale, and did not show an improvement in the mortality rate as a single primary endpoint. At present, we recommend that it is reasonable to perform His bundle pacing instead of RV pacing in patients with atrioventricular block who have an indication for permanent pacing with 36%>LVEF>50% and who are expected to require ventricular pacing over time. However, for patients with normal cardiac function, the adverse effects of RV pacing on LV performance can be expected to be insignificant; therefore, an indication for His bundle pacing should be carefully considered. Additionally, upgrading to His bundle pacing in patients with preexisting standard RV pacing and moderately reduced LVEF (36%–50%) may impose an additional risk of lead extraction or lead implantation, and the clinical evidence of this challenge is not adequate. Implantation of His bundle pacing lead in patients with sick sinus syndrome but without a conduction system disturbance may cause iatrogenic injury to the conduction system; therefore, the indication for His bundle pacing should be very carefully considered. The efficacy of His bundle pacing in patients who had been proven to be non-responders to CRT was evaluated in 2 small-scale studies45-48 (Barba-Pichardo et al [n = 16]45 and Sharma et al [n = 8],48 which demonstrated a significant improvement in LVEF after His bundle pacing (LVEF increased from 29% to 36% and from 30% to 38%, respectively). Sharma et al evaluated His bundle pacing in 25 patients in whom CRT was impossible due to trans-venous LV pacing failure, and found an improvement in NHYA class and reduction in heart failure admissions (Table 8).48 Comparison between pre- and post-HBP. LVEF, NYHA class, and reduction in LAD, LVESD, and LVEDD significantly improved Comparison of the two groups. LVEF, NYHA class and distance of 6-min walk in both groups significantly and equally improved Comparison between pre- and post-HBP. LVEF, NYHA class, and reduction in LVEDD significantly improved Comparison between pre- and post-HBP. LVEF and NYHA class significantly improved, but the reduction in LVEDD did not. As for cases with a previous LVEF ≤35% (n = 72), LVEF improved from 25% to 40% Group 1: LVP failure (n = 25), CRT non-responder (n = 8) Three different clinical studies attempted to perform His bundle pacing antecedently in candidates for CRT (Table 8).45-48 One randomized study compared the efficacy of HBP to that of CRT using a crossover study design in 29 patients, and showed a significant improvement in LVEF and NYHA functional class for whichever method that was used.46 Furthermore, 2 other single-arm observational studies demonstrated a significant improvement in LVEF and NYHA functional class.47, 48 As there are no data showing the long-term superior efficacy of His bundle pacing over CRT, and because a pacing impulse delivered at the His bundle may fail to capture the left bundle in patients with left bundle branch block, antecedent His bundle pacing without a CRT attempt is difficult to recommend. Therefore, His bundle pacing in candidates for CRT can be considered as an alternative option when (1) heart failure is deteriorating even after CRT, when there is (2) no optimal cardiac vein for LV pacing, (3) an unacceptable increase in the LV pacing threshold, (4) unavoidable phrenic nerve stimulation, (5) repeated dislodgement of the trans-venous LV lead, (6) technical limitations, or when (7) CRT is impossible due to complications or the clinical situation. To resolve several problems of His bundle pacing, such as an increase in the pacing threshold and inability of left bundle capture in patients with complete left bundle branch block, a novel technique has emerged, aimed at pacing the left bundle directly by implanting a pacing lead at a distal site on the ventricular septum toward the LV.49-61 Although this method has been shown to be superior to His bundle pacing in reducing the pacing threshold,59 several concerns have been reported49, 61: perforation of the ventricular septum, injury to the conduction system, dislodgement of the lead, injury to the coronary artery (septal branch) and thromboembolism.51, 59-61 Furthermore, because the follow-up intervals of the studies49, 50, 56 were ≤3 months, the long-term efficacy of left bundle pacing has not been clarified. Some investigators have assumed that left bundle branch pacing can be an alternative method to CRT; however, the significance of this method is still unknown owing to the lack of evidence from a randomized clinical trial including a large number of heart failure patients.58 Whether to deactivate an implantable cardioverter defibrillator (ICD) that was implanted and has been maintained before the patient had reached the end of life remains controversial. Shock therapy not only causes pain to the patient but also distresses the family members who provide care for the patient, thereby contradicting the purpose of palliative care in terminally ill patients. A retrospective observational study of 49 ICD patients who were considered to be near the end of life notwithstanding any cardiovascular disease reported that 42.9% experienced ICD activation within the year before death. Moreover, ICDs were not deactivated in 24.5% of patients, even after an end-of-life diagnosis was made, and only one-third of ICDs were deactivated.62 A subanalysis of data from the MADIT-II study, which reported the ICD therapy status in 98 terminally ill patients, revealed that of 47 patients without ICD deactivation who did not establish Do Not Attempt Resuscitation (DNAR) orders, 6 (13%) experienced ICD shock therapy within 1 week before death, and 9 (19%) experienced ICD shock therapy within 24 hours of death.63 A Swedish observational study reported that 32 of 65 ICD patients with DNAR orders had deactivated ICDs, and 10 of 33 patients without deactivation experienced ICD shock therapy within 24 hours of death.64 Among 51 ICD patients who were diagnosed with end stage heart failure at the Tokyo Women's Medical University Hospital between 2010 and 2018, 12 of 39 patients with DNAR orders had deactivated ICDs. In addition, 21 patients (41%) experienced shock therapy within 3 months before death, 14 patients (27%) experienced shock therapy within 1 month before death, and 12 patients (24%) experienced electrical storms (including antitachycardia pacing) within 1 month before death.65 Thus, the worsening condition of terminally ill patients might contribute to the development of ventricular arrhythmias requiring ICD therapy. To avoid painful shock from the viewpoint of palliative care, cardiologists and healthcare professionals should discuss deactivation of ICDs in patients with end stage disease with the patients/family members (Table 9). Regarding the deactivation of ICDs, discussion is required before confirming the will of patients and families during the planning of end-of-life care based on advance care planning (ACP). This process needs to consider the ethics, cognitive ability of patient, etc, and judgment should be made not only by cardiologists and nurses but also based on consultation with palliative care and medical teams (including psychiatrists and psychologists); sufficient informed consent, depending on the individual situation, should be provided (Figure 1).4 The preparation of ACP directives at the end of life plays an important role with respect to the patient's will. Of course, the content of such directives can be subsequently changed. The HRS Expert Consensus Statement states that communication on ICD deactivation is essential; communication is an ongoing process that starts when informed consent is obtained prior to ICD implantation and continues as the patient's condition and treatment goals change with disease progression.66 However, a previous report found that only 4% of patients discussed ICD deactivation with their physician in the clinical setting.67 According to the survey results of ICD patients with malignancies whose prognoses were relatively easy to predict, 35.3% of patients with stage IV cancer underwent ICD deactivation.68 Thus, there are several possible reasons for disconnecting between the recommendations and actual clinical situations. Medical staff do not actively discuss end-of-life topics and tend to postpone certain issues, such as the deactivation of ICDs, until just before death.69 A survey in the USA reported that some clinicians thought that a DNAR order did not mean that ICD should be deactivated, and one-quarter of clinicians thought that ICD deactivation was ethically considered suicide assistance.67 Besides deactivation, not replacing the device is another option for treatment withdrawal. In addition, ICD can be deactivated while maintaining bradycardia pacing or biventricular pacing to prevent the worsening of heart failure symptoms and impairment of quality of life. These decisions should be determined following the steps described above. In ICD patients who are at the end of life notwithstanding any cardiovascular disease, the deactivation decision should be made closely with clinical psychologists, psychiatrists, and palliative care teams based on full evaluations of the psychological and physical stresses caused by ICD shock therapy while maintaining good communication with the patient's family. Early removal of the total device system (the device and all leads) is a Class I indication for a definite CIED infection, such as device pocket infection or lead infection with vegetation, regardless of whether there are any systemic infection symptoms or bacteremia. Early removal of the total device system is not always a Class I indication for bacteremia without a definite device-related infection. First-line management should be investigation of the infection focus, removal of all easily extracted lines, such as a central venous catheter and temporary pacing wire, and administration of antibiotics based on susceptibility testing results for identified bacteria. If the infection focus is unclear and the clinical course is poor, an indication for lead extraction should be considered based on the pathogenic bacteria, the patient's status, and the risk related to lead extraction.70 The following recommendations for lead extraction are based on specific pathogenic bacteria. Early removal of the total device system is recommended for patients with an implanted CIED device and an occult blood stream infection caused by Staphylococcus aureus, coagulase-negative staphylococci (CNS), Propionibacterium spp., or Candida spp. Staphylococcus aureus is an especially virulent bacterium that can cause tissue-destructive effects and severe clinical symptoms.71 CNS, such as S epidermidis, are weakly pathogenic bacteria; however, the incidence of device pocket infections due to CNS is high.72 Propionibacterium spp. are Gram-positive anaerobic rod bacteria that produce a biofilm similar to S aureus and CNS, resulting in antibiotic refractoriness in cases where the device remains in the patient.73 Candida spp. may cause a refractory blood stream infection, especially in compromised hosts, due to biofilm production.74 Early lead extraction is recommended for bacteremia caused by alpha-/beta-hemolytic Streptococcus spp. and Enterococcus spp. Lead extraction should also be attempted if the bacteremia is recurrent or refractory to antibiotic therapy. The risk of a concomitant infection with the device is considered low.75 Lead extraction is recommended if the bacteremia from Gram-negative bacteria or S pneumoniae is recurrent or refractory to antibiotic therapy. The risk of a concomitant infection with the device is considered low, and antibiotic therapy only may be curative.75 A superficial pocket infection does not reach the device, is caused by surface skin closure sutures, and occurs within 30 days of device implantation. Oral antibiotics effective against Staphylococcus aureus should be administered and local lesion care to the superficial infection site is mandatory for at least 7-10 days until pocket redness and systemic symptoms, such as fever and inflammatory reactions, disappear. Superficial lesions should be treated in the same way as device infections if the le

1457P The end-of-life experiences for cancer patients with COVID-19 across the two peak pandemic waves

The COVID-19 (C-19) pandemic has seen much research scrutinising the impact of C-19 on cancer patients, focusing on understanding the impact of a cancer diagnosis and anti-cancer treatments on mortality. Yet there is paucity of work regarding the end-of-life care (EOLC) for cancer patients dying with C-19. Retrospective record review of all non-ventilated patients who died in a tertiary referral UK cancer centre with known or suspected C-19 across the 2 peak pandemic waves from 25/03/20 – 01/05/20 and 05/12/20 – 01/03/21. Demographics and risk factors for severe C-19 were described. EOLC assessment considered palliative care (PC) needs, medications prescribed and advance care plans including Treatment Escalation Plans (TEP) and Do Not Attempt Resuscitation (DNAR) orders. 34 patients were included. Most patients were female (18) and White British (19), mean age was 69 (45-82). 8 patients had recognised cardiovascular risk factors; 11 patients had no comorbidities additional to cancer. 26 patient had metastatic disease, 30 were receiving palliative treatment. Most patients were referred to PC for symptom control (20), 8 were referred for EOLC. All patients had DNAR orders and TEPs. The median number of PC reviews was 5 (range 1-24). Integrated Palliative Outcome Scale (IPOS) (a holistic assessment tool used in clinical care) scores on first assessment (n=24) recorded the main symptoms as weakness, lacking peace and anxiety. Family anxiety was the highest scoring aspect. Medical management at the end-of-life was, however, generally uncomplicated; total opioid (oral morphine equivalent) and benzodiazepine doses administered in last 24 hours before death were relatively low, median dose (range) 30mg (5-180 mg) and 10mg (0-30mg) respectively. With prompt recognition and access to standard EOLC, the symptom management of cancer patients dying from C-19 is relatively uncomplicated. As a transmissible disease, associated with social anxiety and restrictions, death from C-19 is, however, undeniably complicated. Timely acknowledgment of the vulnerability of patients with advanced cancer and C-19 is essential to facilitate early communication about patients’ priorities and wishes, and enhance family support.

Advance care planning from the penultimate hospitalization in patients with end-stage heart failure: a single-center, 10-year experience.

Advance care planning (ACP) is a key element of palliative care even in patients with heart failure (HF); however, the complexity of the clinical trajectory hampers its early introduction. We retrospectively evaluated the state of implementation and the quality of ACP from the penultimate hospitalization in patients with HF who died after repeated hospitalizations. Of the 1117 patients admitted to Saga University Hospital from 2007 to 2016, we excluded 934 patients who survived after discharge or changed hospital, 78 patients who died for a reason other than HF, 42 patients who died during their first HF hospitalization, and 23 patients who died during hospitalization in another hospital. The electronic medical records of the remaining 40 patients were evaluated by three trained physicians on the recently provided 12 recommended elements of ACP, using a 5-point Likert scale (1 = very poor to 5 = excellent). The mean ratings of the 12 ACP elements ranged from 1.0 to 1.9. A do not attempt resuscitation (DNAR) order was issued to 10 patients (25%) just before they died. Of the remaining 30 patients not issued a DNAR order, cardiopulmonary resuscitation was attempted for 23 (76.7%) patients. Among patients with HF who eventually died after repeated hospitalizations, ACP even after the penultimate hospitalization was not evaluated highly. It resulted in a DNAR order in the last few days, a CPR as if their death was sudden and unexpected at the final moment, or CPAOA.

Realizing the Wishes of Terminal Patients: Caregiving Transport Efforts for End of Life in the Kuji Area of Japan.

Background: There are some restrictions in Japan regarding end-of-life care. For example, only physicians can legally issue death certificates. By law, ambulance staff members perform cardiopulmonary resuscitation (CPR) for all patients with cardiopulmonary arrest (CPA). Therefore, it is difficult to transport patients to hospitals without CPR, even in cases of terminal patients with do-not-attempt-resuscitation (DNAR) order. Furthermore, there is no 24-hour home care nursing system in our area. Therefore, terminal patients are unable to spend their last moments at their home in the Kuji area.Objective: To design a system in which terminal patients who wish to spend their final moments at their home can be transported to the hospital without CPR after at-home CPA and a system to avoid confusion between ambulance staff and family members using instructions provided by the physician.Setting/Subjects: The subjects were terminal patients with DNAR order who wanted to stay at home. The instruction to not perform CPR after CPA was created as a document by physicians. Patient information was shared with the fire department; patients were transported to our hospital without CPR after at-home CPA.Results: In total, 26 patients died during the study period; eight received emergency transport to the hospital without CPR after CPA. CPR was not performed for any patient.Conclusion: A system transporting terminal patients without CPR after CPA was necessary in our area. This instruction allows terminal patients to spend their last moments where they wish and avoids unwanted CPR and troubles after CPA.

Advanced do-not-attempt-resuscitation directives and emergency medical services for out-of-hospital cardiopulmonary arrest patients in Japan: a pilot study.

AimsWe investigated how do‐not‐attempt‐resuscitation (DNAR) orders are currently used, and we examined the emergency medical team responses for out‐of‐hospital cardiac arrest (OHCA) cases in Japan.MethodsThe sample for this prospective study comprised all OHCA cases attended to by the Sagamihara Municipal Fire Department emergency medical services between May 30, 2019 and February 15, 2020. Data were recorded by the responding emergency medical team.ResultsThere were 396 OHCA cases. The mean age was 75 ± 18 years, and individuals aged 65 years or older accounted for 80.6%. Approximately 70% of the patients had an underlying disease. A DNAR order was available in only 45 (11.4%) of the cases, of which 12 (26.7%) were written, 27 (60%) were verbally confirmed, and six (13.3%) were confirmed in some other way or both. The home physician was present and able to confirm the patient’s death in only one of the DNAR cases. In 43 (95.6%) of the cases, the emergency medical team carried out cardiopulmonary resuscitation despite a DNAR order; of them, a total of 17 (37.8%) patients were transported to a tertiary emergency hospital.ConclusionsOur analyses indicate the under‐utilization of DNAR advance directives and advance care planning (which are important for better end‐of‐life care) in Japan. Currently, an emergency medical team could be required to attempt resuscitation against an individuals’ clear DNAR order. In the future, legal arrangements regarding the handling of DNAR directives on site may be required to respect patients’ wishes.

Deactivation of implantable cardioverter defibrillator in Japanese patients with end-stage heart failure.

BackgroundDespite the effectiveness of implantable cardioverter defibrillators (ICDs) in the prevention of sudden cardiac death, shock therapy causes patients to experience pain and psychological distress, which contradicts the purpose of palliative care. It is difficult to predict the time course for heart failure (HF) patients, unlike that for cancer patients. The aim of this study was to evaluate the deactivation status of ICD therapy in Japanese patients with end‐stage HF.MethodsWe retrospectively studied 51 ICD patients who died due to worsening HF at Tokyo Women's Medical University Hospital from 2010 to 2019. The frequency of ICD therapy delivered before death and information about the discussion of deactivation and do not attempt resuscitation (DNAR) decisions were reviewed using medical charts.ResultsOf 51 patients, 12 (24%) patients deactivated ICD therapy and seven patients underwent deactivation within 24 hours of a DNAR order. The median time from deactivation to death was 3 days (range, 0‐56). Of 39 patients with DNAR orders, 27 (69%) did not undergo deactivation. A relatively high proportion of patients (n = 14, 27%) experienced ICD shocks within 1 month of death. The frequency of electrical storms within 1 month of death was also high (n = 12, 24%).ConclusionsOur study showed that only one‐fourth of Japanese patients with end‐stage HF underwent deactivation of ICD therapy. A relatively high frequency of shock therapy was observed in the last month before death.

Nurses' perceptions of medical procedures and nursing practices for older patients with non-cancer long-term illness and do-not-attempt-resuscitation orders: A vignette study.

AimTo elucidate influence of a do‐not‐attempt‐resuscitation (DNAR) order on nurses’ perceptions of the medical procedures and nursing practices for non‐cancer older patients.DesignA vignette‐based questionnaire study.MethodsA questionnaire survey asking nurses their perceptions of clinical practices for the following three vignettes was performed in a community hospital in Japan (N = 120): the control vignettes with an older patient with repeated heart failure who was living alone and the other two with either an absence of relatives or a diagnosis of dementia. We also prepared additions to each vignette describing a DNAR order.ResultsNurses’ perception on cardiopulmonary resuscitation, defibrillation, blood tests and intravenous nutrition showed statistically significant and minimally important declines after the DNAR order compared with before for all three vignettes (p < .001). DNAR orders can influence nurses’ perceptions of clinical practices for non‐cancer older patients with chronic heart failure.

Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) score in an East Asian population

AimThe Good Outcome Following Attempted Resuscitation (GO-FAR) score is useful for identifying patients post-arrest with very poor neurologic outcomes and may thus be utilized when counseling family members on do-not-attempt-resuscitation (DNAR) order. We validated the GO-FAR score for neurologically intact survival in patients with in-hospital cardiac arrest (IHCA) in an East Asian country in which DNAR order not common. MethodsRetrospective study about patients who experienced IHCA from 2013 to 2017 with a primary outcome of neurologically intact survival, defined as a CPC score 1 or 2 at discharge. GO-FAR score categorizes the patients into 4 groups: a very low (<1%), low (1%–3%), average (>3%–15%), or higher than average (>15%) likelihood of neurologically intact survival. ResultsOf the 1011 included patients, the rates of survival discharge and neurologically intact survival at discharge were 25.4% and 16.0%, respectively. The area under the receiver operating characteristics curve of GO-FAR score for good neurological outcome was 0.81 (95% CI, 0.78–0.84). Patients with low or very low probability of survival had a likelihood of 0.9% (95% CI, 0.0–2.0), but for those under 40 years old, it was increased to 4.2% (95% CI, 0.0–12.2). Patients with average or above-average probabilities had likelihoods of of 18.5% (95% CI, 15.3–21.6) and 50.5% (95% CI, 40.6–60.5), respectively. ConclusionsThe GO-FAR score well-predicted the neurologically intact survival of East Asian patients with IHCA. This tool may be used as part of a shared decision regarding DNAR orders.

Absence of Relatives Impairs the Approach of Nurses to Cardiopulmonary Resuscitation in Non-Cancer Elderly Patients without a Do-Not-Attempt-Resuscitation Order: A Vignette-Based Questionnaire Study.

A Do-Not-Attempt-Resuscitation (DNAR) order solely precludes performing cardiopulmonary resuscitation (CPR) following cardiopulmonary arrest. A patient's personal status is known to influence a range of clinical practices, not only CPR, when a DNAR order is given. We assessed whether the absence of supporting relatives or a diagnosis of dementia can influence nurses' perceptions of clinical practices for elderly patients with non-malignant and chronic diseases. A vignette-based questionnaire was used to evaluate nurses' beliefs both before and after issuance of a DNAR order. Three vignettes were developed: the control vignette described an 85-year-old woman with repeated heart failure, the second and third incorporated a lack of relatives and a dementia diagnosis, respectively. The survey assessed the approach of nurses to 10 routine medical procedures, including CPR, clinical laboratory testing and nursing care, using a 5-base Likert-scale, for six vignette scenarios. A questionnaire was completed by 186 nurses (64% response). The pre-DNAR non-relative vignette showed significantly lower scores for CPR, indicating a deterioration in willingness to perform CPR, compared to the pre-DNAR control (median [interquartile]; 3 [2-4] and 4 [3-4] in the non-relative and control vignettes, respectively, p < 0.001). No significant differences were observed between the dementia and control vignettes. Absence of contactable relatives and resultant lack of communication can diminish the perception of nurses regarding the provision of CPR, even when a DNAR does not exist. This result suggests a necessity for comprehensive training all medical staff about issuance of DNAR orders and what care should be provided thereafter.

Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units

To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs). We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation. Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death. From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.

Do not attempt resuscitation (DNAR) conversation is not only ICU responsibility: experience as an emergency physician in Qatar

In a busy and hectic critical care setting, sometimes an ‘emergency’ Do Not Attempt Resuscitation (DNAR) conversation has to take place to prevent unnecessary ‘futile care’. Traditionally, this is the responsibility of Intensive Care Unit (ICU) doctors after discussion with family members, or by the primary care doctors after discussion with patients themselves prior to them becoming critically ill. Many critically ill patients with known ‘terminal illnesses’ brought to the Emergency Department (ED) in Qatar do not have a DNAR order. Increasingly, DNAR conversation is being undertaken by Emergency Physicians (EP), alongside ICU doctors. Often, these difficult conversations with family members occur in the ED prior to escalating resuscitation, if time permits. In Qatar, three physicians need to sign the DNAR order if they think it is clinically appropriate. Patients or their family members do not need to sign. However, hospital regulation allows it only after discussion with and agreement from them. Often, the DNAR order also includes the maximum intervention agreed. Some family members object the DNAR order, and insist on ‘full resuscitation’ and organ support, despite explanation of the poor prognosis, and the likelihood of non-curable deterioration. This review looks at the current practice, challenges and evolution of ‘emergency’ DNAR conversation in critically ill adult patients in Qatar.There are at least two different ‘opposing’ approaches to DNAR discussion with patients (and more often the case with family members of patients in critical care setting). The most often used is the patients’ choice approach1. In some society, patients discuss openly with their doctors about their condition fairly early on in the course of their illness. When they become critically ill, a similar discussion is undertaken with family members (or surrogates). A lot of emphasis is put on personal choices and preferences. Another approach, is a physician's driven DNAR recommendation when the clinical circumstance is appropriate2. This happens more commonly when patients present to hospital in late stages of their terminal illness (or with acute deterioration) without any DNAR order. In certain societies, DNAR is not generally discussed unless the condition is acute, life-threatening and the likelihood of a meaningful recovery becomes extremely small.Both approaches are probably the two ends of the same spectrum (see Diagram 1). Both involve risk-benefit discussion (and likelihood of success with good outcome) of cardiopulmonary resuscitation (CPR) in the event of deterioration and cardiac arrest. Having agreed on a DNAR status does not mean that the patient will get substandard care. Patients and families have to be reassured of this fact. Given the appropriate care, many patients with DNAR status recover from their acute illness episodes and are successfully discharged home after emergency hospitalization3. An appropriate DNAR order will guide the medical team (doctors and nurses) to avoid unnecessary ‘futile care’, and hopefully lead to ‘better’ personalized care for patients and their families4.

Prearrest prediction of favourable neurological survival following in-hospital cardiac arrest: The Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score

BackgroundA prearrest prediction tool can aid clinicians in consolidating objective findings with clinical judgement and in balance with the values of the patient be a part of the decision process for do-not-attempt-resuscitation (DNAR) orders. A previous prearrest prediction tool for in-hospital cardiac arrest (IHCA) have not performed satisfactory in external validation in a Swedish cohort. Therefore our aim was to develop a prediction model for the Swedish setting. MethodsModel development was based on previous external validation of The Good Outcome Following Attempted Resuscitation (GO-FAR) score, with 717 adult IHCAs. It included redefinition and reduction of predictors, and addition of chronic comorbidity, to create a full model of 9 predictors. Outcome was favourable neurological survival defined as Cerebral Performance Category score 1–2 at discharge. The likelihood of favourable neurological survival was categorised into very low (<1%), low (1–3%) and above low (>3%). ResultsWe called the model the Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score. The AUROC was 0.808 (95% CI 0.807–0.810) and calibration was satisfactory. With a cutoff of 3% likelihood of favourable neurological survival sensitivity was 99.4% and specificity 8.4%. Although specificity was limited, predictive value for classification into ≤3% likelihood of favorable neurological survival was high (97.4%) and false classification into ≤3% likelihood of favourable neurological survival was low (0.6%). ConclusionThe PIHCA score has the potential to be used as an objective tool in prearrest prediction of outcome after IHCA, as part of the decision process for a DNAR order.

Systematic Review of Typologies Used to Characterize Clinical Ethics Consultations

Classifying the ethical issues in clinical ethics consultations is important to clinical practice and scholarship. We conducted a systematic review to characterize the typologies used to analyze clinical ethics consultations. We identified empirical studies of clinical ethics consultation that report types of ethical issues using PubMed. We screened these articles based on their titles and abstracts, and then by a review of their full text. We extracted study characteristics and typologies and coded the typologies. We reviewed 438 articles; 30 of the articles fulfilled our inclusion criteria. We identified 27 unique typologies. Each typology contained five to 47 categories (mean was 18). The most common categories were DNAR (do-not-attempt-resuscitation) orders (19 of the 27 typologies, or 70 percent), capacity (18 of the typologies, or 67 percent), withholding (18 of the typologies, or 67 percent), withdrawing (17 of the typologies, or 63 percent), and surrogate or proxy (16 of the typologies, or 59 percent). Only seven (26 percent) of the typologies contained all five of the most common categories. The typologies we used to characterize clinical ethics consultation exhibit significant heterogeneity and several conceptual limitations. A common typology is needed whose development may require multi-institutional collaboration and could be facilitated by professional organizations.