End‐of‐life Decision‐making for Patients Admitted Through the Emergency Department: Hospital Variability, Patient Demographics, and Changes Over Time

Richardson, Derek; Zive, Dana; Newgard, Craig D.

doi:10.1111/acem.12112

Cited by 28 publications

(28 citation statements)

References 25 publications

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“…The frequency of DNACPR orders established within the 72 h after admission was 53%, which is higher than the data previously documented in the scientific literature (8.6-24% and even 40% in a nursing home) [6][7][8][12][13][14][15]. Only 39% of these decisions involved the patients and/or their relatives.…”

Section: Prevalence Of the Dnacprmentioning

confidence: 80%

“…Previous studies documented that the rate of DNACPR order among patients is variable: 8.6 to 24% for hospitalized patients [6][7][8][12][13][14][15] and up to 40% in nursing homes [16]. Several factors are associated with the DNACPR order: older age [7,12,16,17], presence of several comorbidities [12,[17][18][19], oncologic status [7,12,19], psychiatric disease [7], poor quality of life [7,17] and poor prognostic [7,17].…”

Section: Introductionmentioning

confidence: 99%

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Patients' characteristics associated with the decision of “do not attempt cardiopulmonary resuscitation” order in a Swiss hospital

Chevaux

Gagliano

Waeber

et al. 2015

European Journal of Internal Medicine

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Section: Prevalence Of the Dnacprmentioning

confidence: 80%

Section: Introductionmentioning

confidence: 99%

Patients' characteristics associated with the decision of “do not attempt cardiopulmonary resuscitation” order in a Swiss hospital

Chevaux

Gagliano

Waeber

et al. 2015

European Journal of Internal Medicine

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“…8-10 Prior studies have elaborated on the substantial variability that exists in LST orders based on differences in patient, family, provider, and institutional factors. 3, 4, 7, 11-30 However, these studies have primarily focused on specific populations such as patients in the intensive care unit (ICU), patients with selected diagnoses, or those with a poor prognosis; they also focus primarily on the addition of new LST limitations. 13, 16, 31-37 …”

Section: Introductionmentioning

confidence: 99%

The Natural History of Changes in Preferences for Life‐Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults

Escobar

Halpern

et al. 2016

J American Geriatrics Society

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Objectives To examine the differences in code status changes and subsequent mortality between younger and older inpatients. Design Retrospective cohort study Setting Kaiser Permanente Northern California (KPNC) Participants Patients hospitalized at 21 KPNC hospitals between 2008 and 2012 Measurements We categorized 227,252 inpatients into young, elderly, and very elderly age groups (<65, 65-84, and ≥85 years, respectively). We evaluated the effect of age on adding new and reversing prior life-sustaining treatment (LST) limitations. We compared survival to inpatient discharge by age group after adding new LST limitations. Results At admission, 18,256 (54.2%) of the very elderly and 18,349 (20.8%) of the elderly had a non-full code order, compared with 3,258 (3.1%) of the young patients. Among the 187,664 patients admitted as full code, 15,932 (8.5%) added new limitations; among the 39,861 patients admitted with LST limitations, 3,017 (7.6%) had these reversed. New limitations were more likely to be seen in older patients (odds ratio (OR)=2.27, 95% confidence interval (CI)=2.16-2.39 for elderly; and OR=6.43, 95% CI=6.05-6.84 for very elderly), and reversals of prior limitations were less likely to be seen in older patients (OR=0.73, 95% CI =0.65-0.83 for elderly; and OR=0.46, 95% CI=0.41-0.53 for very elderly), compared with younger patients. Among those who added new limitations, survival rates were 71.7% in very elderly, 57.2% in elderly, and 43.4% in young patients (p<0.001). Conclusion Changes in code status were common among hospitalized patients. Age was a key determinant in the likelihood of adding new or reversing prior LST limitations. Compared with younger patients, older patients who added LST limitations were more likely to survive to hospital discharge.

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“…for CPR rather than DNACPR) 16 and discussing CPR decisions in the context of overall treatment plans were received more positively than those focusing on not attempting resuscitation. 17 The provision of tools to aid structured discussion 18 and the normalising of discussions about resuscitation so that it was part of an overall discussion of treatment were also helpful. During discussions care is required to ensure that the use of medical jargon does not lead to misunderstandings.…”

Section: Discussionmentioning

confidence: 99%

“…There is significant regional and international variation in how DNACPR orders are approached, with many institutions initiating changes to improve DNACPR practice. 17,18 DNACPR decisions are broadly based around three categories; these are:…”

Section: Do-not-attempt-cardiopulmonary-resuscitation Ordersmentioning

confidence: 99%

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

Perkins

Griffiths

George

et al. 2016

Health Serv Deliv Res

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BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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End‐of‐life Decision‐making for Patients Admitted Through the Emergency Department: Hospital Variability, Patient Demographics, and Changes Over Time

Cited by 28 publications

References 25 publications

Patients' characteristics associated with the decision of “do not attempt cardiopulmonary resuscitation” order in a Swiss hospital

Patients' characteristics associated with the decision of “do not attempt cardiopulmonary resuscitation” order in a Swiss hospital

The Natural History of Changes in Preferences for Life‐Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults

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

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