An audit of “do not attempt resuscitation” decisions in two district general hospitals: do current guidelines need changing?

Abstract

Introduction: Doctors in all specialties are involved in making ''do not attempt resuscitation'' (DNAR) decisions; this can be a difficult and challenging process. Guidelines exist to provide an ethical and legal framework for the process and documentation of these decisions. Objective: To audit the documentation of resuscitation decisions in a sample of medical inpatients from two district general hospitals. Method: A retrospective case note audit of 50 medical inpatients, in which a DNAR decision had been made (28 from hospital 1, 22 from hospital 2). Results: Average age was 78.9 years (48% male:52% female). In both hospitals DNAR decisions were usually discussed with relatives (84%), documented in nursing notes (100%) and made by senior team members (90%). Although the decision was usually dated and clearly documented (98%), abbreviations were commonly used in hospital 2 (45.5% vs 0% in hospital 1, p,0.05). Decisions regarding other treatment were not consistently documented (78.6% and 72.7%, respectively) and there was little evidence that decisions were reviewed (14.3% and 31.8%). The decision was rarely discussed with the patient (6% of all patients), although 66% of patients were not in a position to have a discussion. Conclusions: Specific forms for recording DNAR decisions improve the clarity of documentation. Current recommendations to discuss resuscitation with patients are controversial and not followed. However, many patients are not in a position to hold a discussion when the need arises and the guidelines should advocate early discussion during a hospital admission in patients where this is appropriate, prior discussion with family and/or wider use of advanced directives.

Including patients in resuscitation decisions in Switzerland: from doing more to doing better

“…This discrepancy between residents’ thresholds and the Ethics Council's threshold for allowing a decision, either CPR or DNAR, without patient involvement, was also found in previous studies,36 37 including in Switzerland,13 and can be interpreted in several ways. First, residents may be rationalising situations when their true reason for not including patients is the anticipation of an emotionally difficult discussion.…”

Factors that influence decisions about cardiopulmonary resuscitation: the views of doctors and medical students

“…Where patients’ or families’ views were sought to inform decisions about CPR, doctors sometimes felt uncomfortable ignoring their wishes and this appeared to be associated with a reluctance to discuss CPR more openly. A number of studies have found that discussions rarely take place with patients and their families12 36 37 38 and doctors often feel uncomfortable initiating such discussions 20 21 22 23. Our findings illustrate that some doctors may feel in some way obliged to follow patients’ wishes, where known, to provide CPR where they feel it would be ineffective.…”

Barriers to involving older people in their resuscitation decisions: the primary-secondary care mismatch highlights the potential role of general practitioners

“…A point of contention from this guidance relates to patient involvement in resuscitation decisions. Studies repeatedly find that doctors are less likely to involve patients(5–8), although they frequently discuss these decisions with relatives(2,8,9). Reasons for this paradox include feeling uncomfortable with end‐of‐life discussions(1,8), fear that it may cause undue distress to the patient or be inappropriate at that time (6) or take away hope.…”

“…A point of contention from this guidance relates to patient involvement in resuscitation decisions. Studies repeatedly find that doctors are less likely to involve patients (5)(6)(7)(8), although they frequently discuss these decisions with relatives (2,8,9). Reasons for this paradox include feeling uncomfortable with S U M M A R Y Background: 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) orders are made frequently for older people in hospital.…”