The Universal Form of Treatment Options (UFTO) as an Alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Orders: A Mixed Methods Evaluation of the Effects on Clinical Practice and Patient Care

Abstract

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

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

“…Over half (20/37) of the studies were conducted in the USA, 22,25,[28][29][30][31]39,41,42,45,[47][48][49][50][52][53][54][55][56][57] nine were conducted in the UK, 26,[32][33][34][35]37,40,43,44 two were conducted in Australia 23,24 and one study was conducted in each of Germany, 46 Belgium, 38 Switzerland, 51 the Netherlands, 16 Singapore 36 and Saudi Arabia. 27 …”

“…Of the 37 studies, eight were randomised controlled trials, [22][23][24]30,45,54,55,57 27 were before-and-after studies 16,[25][26][27][28][29][31][32][33][34][35][36][37][38][39][40][41][42][43][44][48][49][50][51][52][53]56 and two were cluster controlled studies. 46,47 Two studies were assessed as providing strong evidence, 24,40 12 were assessed as providing moderate evidence 16,22,23,29,30,[35][36][37][38]54,55,…”

“…46,47 Two studies were assessed as providing strong evidence, 24,40 12 were assessed as providing moderate evidence 16,22,23,29,30,[35][36][37][38]54,55,57 and 23 were assessed as providing weak evidence. [25][26][27][28][31][32][33][34]39,[41][42][43][44][45][46][47][48][49][50][51][52][53]56 REVIEW OF PUBLISHED EVIDENCE NIHR Journals Library www.journalslibrary.nihr.ac.uk…”

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

“…Please offer patients and families the opportunity to discuss the following and document below: This approach was not developed in response to the Tracey case, but preceded it, in recognition of the problems with DNACPR processes that have existed for some time. 5,19 The Universal Form of Treatment Options (UFTO ; Fig 1; see www. ufto.org) contextualises the resuscitation decision among other treatment decisions, so that the conversation can focus on treatments to be had rather than the ones to be withheld, thereby protecting the therapeutic relationship. It steers clear of tick boxes, instead using open text boxes to encourage less refl exive decision-making.…”

“…It is completed for all inpatients, so that consulting about the resuscitation decision can become more routine; there is also less danger of a decision not to resuscitate being confl ated with the anticipation of imminent death. The UFTO and its accompanying information sheet Talking with your doctor was evaluated in a mixed methods, before-and-after study with contemporaneous case controls 5 and was found to be associated with a signifi cant reduction (p<0.001) in harm events (as measured by the global trigger tool) in those patients in whom a decision not to attempt resuscitation had been made.…”