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

Abstract

Summary Background: ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) orders are made frequently for older people in hospital. Sensitive anticipatory discussion is encouraged where possible, but usually this does not happen, despite the evidence suggesting that many older patients would like to be involved in such decisions. Methods: Current clinical practice in both primary care and secondary care and perceived barriers to patient involvement in resuscitation decisions was assessed using a questionnaire in Medicine for the Elderly physicians in two hospitals, and General Practitioners of teaching practices in Norfolk. Results: Response rate was 51% (n = 24/47). Hospital‐based clinicians made DNACPR decisions more frequently, but discussed decisions with patients in less than 25% of cases. By contrast, GPs thought that patient involvement was more important and felt that they had a better understanding of the patient’s wishes due to the long‐term relationship they shared. Mental capacity was seen as the biggest barrier to patient involvement by both groups. Other barriers included lack of understanding, communication difficulties and practical concerns. Conclusion: Further support and training could help clinicians improve their resuscitation decision‐making practice. Advanced discussion in Primary Care with older people before they lose capacity may have a role in increasing their involvement in resuscitation decision making.

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

“…Thirty-seven articles contributed to this theme and 17 included a questionnaire or survey design. 38,[63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78] Of these 17 articles, 12 were deemed low-quality studies, [63][64][65][66][67][68][72][73][74][75][76][77] two were deemed medium quality 38,71 and three were deemed high quality. 69,70,78 Twelve articles included reviews or audits of medical records, registry of deaths or MET calls, 16,75,[79][80][81][82][83][84][85][86][87][88] of which two were of high quality 16,86 two were of medium quality …”

“…It was found that an inappropriate setting, such as a busy ward with a lack of privacy, could limit DNACPR discussions. 77 …”

“…72,87,93 Similarly mentioned were terms such as futility, 77,86 withholding potentially harmful treatment 77 and the likelihood of successful CPR.…”

“…Of the 26 articles in this theme, 16 included cross-sectional questionnaires or surveys, 38,39,[63][64][65]68,70,74,75,77,78,83,93,[95][96][97] of which six were deemed high quality, 70,78,93,[95][96][97] two were deemed medium quality 38,39 and eight were deemed low quality. [63][64][65]68,74,75,77,83 Eight articles included qualitative methods, [13][14][15]89,91,[97][98][99] of which three were of high quality, 15,89,98 four were of medium quality 13,14,91,97 and one was of low quality. 99 The remaining three articles are reviews of records or audits, …”

DNACPR decisions: challenging and changing practice in the wake of the Tracey judgment

“…Although we should accept that doctors are unlikely to be able to convey all of their clinical experience and understanding of the potential outcomes of attempted CPR, we should not be defeatist about trying. Patient information leafl ets, 17 provision of scoring systems, 16 early conversations with familiar practitioners, 18 and increasing public discussion and education will all help.…”