AimsTo determine whether the introduction of the Universal Form of Treatment Options (the UFTO), as an alternative approach to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, reduces harms in patients in whom a decision not to attempt cardiopulmonary resuscitation (CPR) was made, and to understand the mechanism for any observed change.MethodsA mixed-methods before-and-after study with contemporaneous case controls was conducted in an acute hospital. We examined DNACPR (103 patients with DNACPR orders in 530 admissions) and UFTO (118 decisions not to attempt resuscitation in 560 admissions) practice. The Global Trigger Tool was used to quantify harms. Qualitative interviews and observations were used to understand mechanisms and effects.ResultsRate of harms in patients for whom there was a documented decision not to attempt CPR was reduced: Rate difference per 1000 patient-days was 12.9 (95% CI: 2.6–23.2, p-value = 0.01). There was a difference in the proportion of harms contributing to patient death in the two periods (23/71 in the DNACPR period to 4/44 in the UFTO period (95% CI 7.8–36.1, p-value = 0.006). Significant differences were maintained after adjustment for known confounders. No significant change was seen on contemporaneous case control wards. Interviews with clinicians and observation of ward practice revealed the UFTO helped provide clarity of goals of care and reduced negative associations with resuscitation decisions.ConclusionsIntroducing the UFTO was associated with a significant reduction in harmful events in patients in whom a decision not to attempt CPR had been made. Coupled with supportive qualitative evidence, this indicates the UFTO improved care for this vulnerable group.Trial RegistrationControlled-Trials.com ISRCTN85474986 UK Comprehensive Research Network Portfolio 7932

DNACPR orders can act as unofficial 'stop' signs and can often signify the inappropriate end to clinical decision making and proactive care. Many clinicians were uncomfortable discussing DNACPR orders with patients and families. These findings help understand why patients with DNACPR orders have worse outcomes, as such they may inform improvements in resuscitation policies.

KingdomCorresponding author's email: jonathan.fuld@addenbrookes.nhs.uk RATIONALEThere are problems with the current approach to do not attempt resuscitation (DNAR) decisions and documentation. These include ad-hoc completion (making futile resuscitations inevitable) and misconception of the meaning of DNAR orders (clinician and lay perception of less care being appropriate). Yet DNAR does not necessarily mean, "about to die": over 50% of patients with DNAR orders are discharged. For all patients there is evidence that the care they receive is not of the same standard as those with similar illness without the DNAR order in place. This misconception is widely acknowledged, resulting in some clinicians withholding DNAR orders for fear that their patients care will be worsened. METHODSWe conducted a cohort study at an acute hospital to assess the impact of our proposed solution to the problems identified above; the "Universal Form of Treatment Options" (UFTO), (Figure 1). The UFTO is designed to be completed on all patients, placing the resuscitation decision within a broader consideration of best care. The UFTO was developed by an iterative process involving consultation with doctors, nurses and patients, both individually and in focus groups. Initial data collection, through individual case note review, took place over three months and examined standard practice (May-July 2010) This was followed by a period of education about the UFTO in August, and a period of bedding in during September-October 2010 . Data after the introduction of the UFTO was collected during Nov 2010 -Jan 2011. RESULTSThere was no change in whole ward mortality: Overall deaths 56/550 (DNACPR group) versus 58/544 (UFTO group) chi-squared statistic of 0.0 with p=0.872. There was a statistically significant increase in the number of patients in whom a decision not to resuscitate was made 113/587 in the DNACPR group and 140/573 in the UFTO group. Comparison of these proportions gives a =4.27 with p=0.04. Characteristics of patients in whom a decision not to resuscitate was made were similar in terms of Modified early warning score on admission, Charlson comorbidity score, and age (see table 1 ). CONCLUSIONThe UFTO is a feasible alternative to the current DNAR order. The UFTO increased the proportion of patients not for resuscitation with no apparent change in the characteristics of those patients, in keeping with removal of the ad hoc nature of DNAR use. This suggests that the UFTO would lead to fewer inappropriate resuscitation attempts, which has ethical and health economic implications. Figure 1