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BACKGROUND Resuscitation decisions made in advance are especially important to prevent negative patient outcomes at end-of-life. We conducted a clinical audit to assess the current practice of these decisions in Sri Lanka and then introduced interventions to improve the same. MATERIALS AND METHODS An auditor-administered questionnaire developed through a focused group discussion among experts was used to analyze the medical records of deaths during a period of sixty days focusing on advance resuscitation decisions and factors affecting them. The junior doctors directly involved in the care of each patient were interviewed regarding their retrospective judgement about the most appropriate resuscitation decision, which was later compared with the decision of an expert panel, who decided on the most appropriate resuscitation decision based on the medical records of the patient. An educational session for doctors was then conducted to improve their knowledge about advance resuscitation decisions including the importance of meticulous documentation of such decisions. The outcome was assessed after sixty days following the introduction of the intervention using the same questionnaire. RESULTS There was a significant improvement in the number of documented advance resuscitation decisions from 4/40 (10%) to 17/38 (44.73%) (Z = 3.5, P = 0.0006), with a significant increase in DNACPR decisions from 4/40 (10%) to 14/38 (36.8%) (Z = 2.8, P = 0.005) following the intervention. Unsuccessful CPR attempts decreased significantly from 31/40 (77.5%) to 14/38 (36.8%) (Z = 3.6, P = 0.0003) in the post-intervention period. The resuscitation decisions suggested by junior doctors that matched with expert decision increased significantly for both interns ((from 11/40 (27.5%) to 22/38 (57.9%) (Z = 2.7, P = 0.0066)) and registrars ((18/40 (45%) to 27/38 (71.05%) (Z = 2.3, P = 0.0202)) in the post-intervention period. CONCLUSION Documentation and practice regarding advance resuscitation decisions is suboptimal in Sri Lanka. This can be improved by interventions targeting improving the knowledge about the concept and its proper documentation among health care professionals.

Background Pulseless electrical activity (PEA) is managed in accordance with international and national guidelines. These guidelines are not fully evidenced, resulting in emergency medical services in the United Kingdom amending guidelines to support paramedics when making resuscitation decisions. This review examined the local guidelines of services to identify the local clinical management of PEA, summarise the available evidence and prioritise future research. Methods The review was conducted according to the Joanna Briggs Institute systematic review of text and opinion. The review included locally amended guidelines and cited evidence sources for the management of PEA. A three-step search strategy was applied. Textual data was extracted to form conclusions which were categorised into similar meaning and developed into synthesised findings. Results Twenty-two documents met the inclusion criteria; Twenty-seven conclusions were extracted and analysed to generate 10 categories, forming three synthesised themes: the variability in the clinical management of PEA between ambulance services; the early identification of reversible causes and appropriate treatment options to increase survivability; and the consensus for further research. Conclusion This review identified variability in the clinical management of PEA; the autonomy of paramedics, which patients to transport to hospital and the factors applied to inform resuscitation decisions. A summary of the evidence in support of the local guidelines found that the early identification and treatment to reverse the cause of PEA was important to patient survival, however, this was acknowledged as complex and challenging to achieve. There was a consensus to improve patient outcomes using prognostic research.

Introduction A great deal of the literature has focused specifically on true pulseless electrical activity (PEA), whereas there is a dearth of research regarding pseudo-PEA. This narrative review evaluates the diagnosis and management of patients in pseudo-PEA and discusses the impact on emerging patient outcomes. Discussion Pseudo-PEA can be defined as evidence of cardiac activity without a detectable pulse. Distinguishing pseudo-PEA from true PEA is important for emergency physicians as the prognosis and management of these patients differ. POCUS is the tool most commonly used to diagnose pseudo-PEA and there are varying treatment strategies to manage these patients. Identifying patients in pseudo-PEA can help guide resuscitation decisions, and ultimately impact emergency response systems, patients, and families. Conclusions The incidence of pseudo-PEA is increasing. Effective care of these patients begins with early diagnosis of this condition and immediate treatment to warrant the greatest chance of survival. There is a need for further prospective studies surrounding pseudo-PEA as evidenced by the lack of research in the current literature.

Background Evidence suggests that discussing resuscitation with patients and relatives from ethnic minority groups is problematic for healthcare professionals (HCPs), but there is limited evidence exploring these issues or offering guidance for HCPs in navigating these challenging discussions. This study explores the barriers and enablers to HCPs discussing deterioration and resuscitation decisions with patients and families from ethnic minority groups. Results Personal, cultural, religious/spiritual and health beliefs, emotions, and communication quality and skills were discussed. Participants described that the interaction between these factors as complex, impacting the way some patients and families responded to do not attempt cardiopulmonary resuscitation (DNACPR) orders and the particular challenges these pose. Conclusion Key barriers and enablers for healthcare professionals discussing resuscitation with patients and families from Black, Asian and minority ethnic communities were identified. The findings highlight areas of improvement for training, both relating to DNACPR discussions and ‘cultural competence’.

Background Ascertaining and discussing resuscitation status should be a routine part of medical practice. However, it is frequently neglected until a patient is acutely unwell. The National Consent Policy1 recommends that discussion around “Do not attempt cardiopulmonary resuscitation” (DNACPR) orders should occur for patients with “an identifiable risk of cardiorespiratory arrest occurring”. The Clinical Frailty Scale is a useful tool for providing predictive information about the risk of death in older patients2. Along with the presence of comorbidities, it can assist with determining prognosis and identifying patients for whom early discussion about resuscitation status is appropriate. Methods A chart review was carried out of all 106 inpatients in a model 3 hospital. Data was extracted on demographic information, frailty score and resuscitation status. Results The average age of inpatients was 79.8 years. On admission, the average Clinical Frailty Scale score was 5 (mildly frail), with 15% having a frailty score of 7 or more, and 28% a diagnosis of dementia. 25.5% of inpatients had a DNACPR order in place. It took an average of 32.4 days (range 0-224 days) from admission until this decision was made. Conclusion As we are caring for an older population with frailty; care planning, including resuscitation status should be discussed at an earlier stage. Ideally, this should occur on admission for certain patients, particularly those with high levels of frailty and multiple comorbidities. Our current practice, in which DNACPR decisions sometimes take place after a prolonged admission, is suboptimal. A change to the medical admission proforma, adding a prompt for discussion of DNACPR orders will be considered.

Introduction Research shows that ambulance personnel can find it challenging to withhold or terminate resuscitation and manage patient death in the field. This scoping review provides a synthesis of published research that has addressed three main questions. Each relates to ambulance personnel enacting decisions to withhold or terminate resuscitation and manage patient death: How are they prepare; what supports and coping strategies are utilised; and what preparation and support needs have been identified? Methods Using Arksey and O'Malley's five-stage scoping review framework this review identifies what is known and what further research is needed in this area. Results Sixteen methodologically heterogenous papers were located. Half of the studies were conducted in the United States, with the remainder in Canada, Singapore, Spain, Sweden and the United Kingdom. Ambulance personnel receive little formal training and feel unprepared to manage situations where resuscitation is unsuccessful or unwarranted, particularly communicating with family, breaking bad news and managing death scenes. These aspects of termination of resuscitation are so challenging that distancing and avoidance are sometimes used as coping strategies, even when medical futility has been established. In addition to formal counselling for personal loss and stressors, ambulance personnel value downtime and informal peer debriefing, following difficult resuscitation decisions and patient deaths. Conclusion Ambulance personnel feel inadequately prepared to withhold or terminate resuscitation and manage patient death in the field. They want more opportunities to learn about death notification, communication with bereaved families and safe, sensitive management of death scenes. More research is needed to determine how best to prepare and support ambulance personnel for the challenges of resuscitation decision-making and patient death.

Aim To estimate the mortality rate, the rate of return of spontaneous circulation (ROSC) and survival with favorable neurological outcome in patients with COVID-19 after in-hospital cardiac arrest (IHCA) and attempted cardiopulmonary resuscitation (CPR). Methods PubMed, EMBASE, Web of Science, bioRxiv and medRxiv were surveyed up to 8th February 2021 for studies reporting data on mortality of patients with COVID-19 after IHCA. The primary outcome sought was mortality (in-hospital or at 30 days) after IHCA with attempted CPR. Additional outcomes were the overall rate of IHCA, the rate of non-shockable presenting rhythms, the rate of ROSC and the rate of survival with favorable neurological status. Results Ten articles were included in the systematic review and meta-analysis, for a total of 1179 COVID-19 patients after IHCA with attempted CPR. The estimated overall mortality rate (in-hospital or at 30 days) was 89.9% (95% Predicted Interval [P.I.] 83.1%–94.2%; 1060/1179 patients; I2 = 82%). The estimated rate of non-shockable presenting rhythms was 89% (95% P.I. 82.8%–93.1%; 1022/1205 patients; I2 = 85%), and the estimated rate of ROSC was 32.9% (95% P.I. 26%–40.6%; 365/1205 patients; I2 = 82%). The estimated overall rate of survival with favorable neurological status at 30 days was 6.3% (95% P.I. 4%–9.7%; 50/851 patients; I2 = 48%). Sensitivity analysis showed that COVID-19 patients had higher risk of death after IHCA than non COVID-19 patients (OR 2.34; 95% C.I. 1.37–3.99; number of studies = 3; 1215 patients). Conclusions Although one of three COVID-19 patients undergoing IHCA may achieve ROSC, almost 90% may not survive at 30 days or to hospital discharge.

Objective Utilize simulation to evaluate if living wills (LW) or POLST achieves goal concordant Care (GCC) in a medical crisis. Methods Nurses and resident-physicians from a single center were randomized to a clinical scenario with a living will (LW), physician orders for life sustaining treatment (POLST) or no document. Primary outcomes were resuscitation decision and time to decision. Secondary outcome was the effect of education. Results Total enrollment was 57 and less than 30% received prior training. Types of directives were linked to resuscitation decisions (P = .019). Participants randomized to "No Document" or POLST specifying "CPR" performed resuscitation. If a terminal condition presented with a POLST/ do not resuscitate-comfort measures only (DNR-CMO), 73% resuscitated. The LW or POLST specifying DNR combined with medical support resulted in resuscitations in 29% or more of the scenarios. Documents did not significantly affect median time-to-decision (P = .402) but decisions for "No Document" and POLST/CPR were at least 10 s less than other scenarios. Scenarios involving POLST DNR/Limited Treatment had the highest median time of 43 s. Prior training in LWs and POLST exerted a 10% improvement in decision making (P = .537). Conclusion GCC was not always achieved with a LW or POLST. This conclusion supports prior research identifying problems with the interpretation and discordance with LW's and POLST.

Do not attempt cardiopulmonary resuscitation (DNACPR) orders are important in avoiding inappropriate CPR attempts. Clear and full documentation of decisions about CPR, the reasons for them, and the discussions with those involved in the decisions, is an essential part of high-quality care.1 A new combined Queen Elizabeth Hospital King's Lynn DNACPR and Ceiling of Treatment form was implemented in July 2018. A new audit tool was developed by the resuscitation department to ensure accurate completion of DNACPR forms was captured. Subsequent re-audits …

Background There is a dearth of qualitative research on resuscitation preferences of older New Zealanders. The aim of this study was to investigate the resuscitation preferences of older New Zealanders in a retirement village or residential care setting, as well as the reasons for these preferences. Methods This study had 37 participants from two retirement villages in Auckland, New Zealand. Participants were interviewed about a hypothetical case vignette about cardiopulmonary resuscitation, and then they completed a semi-structured interview. Interviews were subsequently transcribed and analyzed by two independent researchers using thematic qualitative methodology. Results The majority of the participants (n = 25, 67.6%) decided against resuscitation, 10 (27.0%) wanted resuscitation, and 2 (5.4%) were ambivalent about their resuscitation preferences. Three main themes emerged during the data analysis regarding participants' reasons for deciding against resuscitation: (i) the wish for a natural death; (ii) advanced age; and (iii) a realistic awareness about the consequences of resuscitation. Responses related to the third these had three subthemes: (i) reduced quality of life; (ii) loss of personal integrity and sense of existence; and (iii) concern that resuscitation could result in unnecessary costs or a burden on others. Among participants who preferred resuscitation, two main themes emerged regarding their reasons for wanting resuscitation: (i) the wish to prolong a good quality of life; and (ii) unrealistic expectations of resuscitation. Conclusions Older people in this study were able to make reasoned decisions about resuscitation based on balancing their subjective estimations of quality of life and the presumed consequences of resuscitation. It is important therefore to educate older adults about the potential outcomes of resuscitation and explore (and document) their reasoning when discussing resuscitation preferences so their wishes can be respected.

Emeritus Professor Alan Glasper, from the University of Southampton, discusses concerns raised by the Care Quality Commission about the imposition of do not resuscitate orders on some patients during the pandemic

Resuscitation decisions for infants born at the edges of viability are complicated moral dilemmas, and the process of making these decisions is emotionally exhausting and morally distressful for families and physicians alike. An ethical approach to making these decisions requires input from physicians and parents; individuals tasked with facilitating such decisions must possess the communication and counseling skills needed to assist families with these painful and life-altering decisions. It is incumbent on all of us to continue our investigation into how we can better assist families in this process while providing care that is in their best interest.

OBJECTIVES:. Early palliative medicine consult in the ICU can significantly improve outcomes in high-risk patients. We describe a pilot study of including a recommendation for palliative medicine consult in the ICU morning huddle. DESIGN:. A prospective, observational, quality improvement study. PATIENTS AND SETTING:. Adult patients (age above 18 yr) admitted with cardiac arrest, stage IV cancer, admission from a long-term acute care facility, and circulatory shock on mechanical ventilation to the medical ICU. INTERVENTIONS:. We aim to assess the effect of an early palliative medicine consultation in selected high-risk patients on change in code status, referral to hospice, tracheostomy, and or percutaneous gastrostomy tube placement. MEASUREMENTS AND MAIN RESULTS:. There were 83 patients who triggered an early palliative medicine consult. Palliative medicine consultation occurred in 44 patients (53%); 23 patients (28%) had a palliative medicine consult within the first 48 hours, 21 (25%) had a palliative medicine consult afterwards. There was a significantly higher number of patients who de-escalated their code status in the palliative medicine consult group compared with the no palliative medicine consult group (63.6% vs 7.7%); however, the number was higher in the late palliative medicine consult group (71.4% vs 56.5%). There were more patients referred to hospice in the palliative medicine consult group. No difference in length of stay was observed. CONCLUSIONS:. Early palliative medicine consultation in the daily ICU morning huddle is achievable, can produce a palliative medicine consultation in most cases, and results in a significant change in code status toward less aggressive measures.

‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions have received a significant amount of attention, in part because of a highly publicized judgement from the Court of Appeal for England and Wales. Updated guidance from professional bodies and a public consultation on the English Emergency Care and Treatment Plan have sparked further debate. This article summarizes some of the key points for clinicians when making DNACPR decisions, including when and how DNACPR discussions should take place. It also suggests examples and methods for how to approach conversations with patients and proxies.

Discussions about your death will never be easy, but Keith Cass describes how social media was useful to him when thinking and talking about resuscitation decisions

Background There have been a number of high profile cases about resuscitation decisions in recent years. 1,2 This has prompted regular updates in the national guidance on decisions relating to cardiopulmonary resuscitation (CPR). 3–5 At the hospice a specific template is used to document CPR decisions on SystmOne, electronic patient record system. Current practice on the inpatient unit was audited against the hospice resuscitation policy following local and national guidance. 3,6 Fourteen standards were set specifically reviewing documentation on admission, at multidisciplinary team meetings and discharge. A 100% target was set for each standard due to the important implications of the do not attempt cardiopulmonary resuscitation (DNACPR) decision. The aim was to establish whether CPR decisions were documented and communicated appropriately to highlight any areas for improvement. Method Retrospective review of 39 patient notes on SystmOne for patients admitted to the hospice from October to November 2016. Results Of the fourteen standards set, only one standard met the 100% target. This was informing the GP of the unified DNACPR (uDNACPR) status at discharge. Standards that achieved over 90% included: making a resuscitation decision on admission and discussing this with the patient, as well as reviewing resuscitation status at multidisciplinary team meetings. Standards that achieved less than 80% included: discussing resuscitation decision with relatives when the patient lacks capacity and documenting decisions for uDNACPR at discharge. Conclusion Using SystmOne templates has been helpful for documenting CPR status on admission, at multidisciplinary meeting review and on discharge letters to the GP. Recommended amendments to the CPR template include a prompt for a uDNACPR decision at discharge and an updated discharge checklist. It is recommended that doctors fully document the CPR discussions when completing these templates even if the uDNACPR is in place, especially with relatives of patients without capacity.

This article addresses the extent to which professional providers of emergency medical services (EMS providers) could be held liable for civil damages when, due to apparent futility, resuscitation ...

Objective To review UK newspaper reports relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in order to identify common themes and encourage dialogue. Methods An online media database (LexisNexis ® ) was searched for UK Newspaper articles between 1993 and 2013 that referenced DNACPR decisions. Legal cases, concerning resuscitation decisions, were identified using two case law databases (Lexis Law ® and Westlaw ® ), and referenced back to newspaper publications. All articles were fully reviewed. Results Three hundred and thirty one articles were identified, resulting from 77 identifiable incidents. The periods 2000–01 and 2011–13 encompassed the majority of articles. There were 16 high-profile legal cases, nine of which resulted in newspaper articles. Approximately 35 percent of newspaper reports referred to DNACPR decisions apparently made without adequate patient and/or family consultation. "Ageism" was referred to in 9 percent of articles (mostly printed 2000–02); and "discrimination against the disabled" in 8 percent (mostly from 2010–12). Only five newspaper articles (2 percent) discussed patients receiving CPR against their wishes. Eighteen newspaper reports (5 percent) associated DNACPR decisions with active euthanasia. Conclusions Regarding DNACPR decision-making, the predominant theme was perceived lack of patient involvement, and, more recently, lack of surrogate involvement. Negative language was common, especially when decisions were presumed unilateral. Increased dialogue, and shared decision-making, is recommended.

Aim We examined how physicians in different medical specialties would evaluate treatment decisions for vulnerable patients in need of resuscitation. Methods A survey depicting six acutely ill patients from newborn infant to aged, all in need of resuscitation with similar prognoses, was distributed (in 2009) to a representative sample of 1650 members of the Norwegian Medical Association and 676 members of the Norwegian Pediatric Association. Results There were 1335 respondents (57% participation rate). The majority of respondents across all specialties thought resuscitation was in the best interest of a 24 weeks' gestation preterm infant and would resuscitate the patient, but would also accept palliative care on the family's demand. Accepting a family's refusal of resuscitation was more common for the newborn infants. Specialists were overall similar in their answers, but specialty, age and gender were associated with different answers for the patients at both ends of the age spectrum. Conclusion Resuscitation decisions for the very young do not always seem to follow the best interest principle. Specialty and personal characteristics still have an impact on how we consider important ethical issues. We must be cognisant of our own valuations and how they may influence care.

This research examined the quality of resuscitation decisions documented in the clinical notes of 99 older patients within 48 h of admission. Only 34 had current documentation that was frequently inconsistent and ambiguous, leaving patients at risk of receiving inappropriate and unwanted resuscitation. Clear guidelines with community input to guide the implementation and documentation of end-of-life decisions are essential.

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.

A comprehensive analysis of this case must examine the roles and obligations of both the pregnant woman and the medical team. Once the ethics consultant has clarified the infant's prognosis, he or ...

PURPOSE OF REVIEW Decisions to forego life-sustaining treatments are complex, and disagreements between physicians and patients occur. This review discusses recent findings regarding what factors influence physicians and patients or their surrogates in these decisions and considers whether futility arguments regarding life-sustaining treatments should be abandoned. RECENT FINDINGS Cardiopulmonary resuscitation is one paradigm in the literature for studying end-of-life decision-making. Outcomes for cardiopulmonary resuscitation are poor, and physicians tend to over-rely on tacit versus evidence-based knowledge for resuscitation decisions. Physician decisions are often inherently biased regarding elderly and intellectually impaired patients. Patient decisions regarding life-sustaining treatments are poorly understood by physicians, and also include inherent bias against the elderly and intellectually impaired. Although patients and their decision-makers frequently incorporate religious or spiritual beliefs in their decisions, physicians rarely discuss these factors with them. Defining 'futility' is problematic, and futility arguments have limited utility in clinical end-of-life treatment discussions. SUMMARY Further research is needed about factors that affect both physicians and patients with regard to forgoing life-sustaining interventions. Physicians need more information regarding religious/spiritual preferences of patients and decision-makers. 'Futility' arguments in end-of-life decision-making are flawed and should probably be abandoned.

Background: t Recent Court of Appeals rulings found failure to discuss DNACPR decision breached Article 8 of the European Human Rights Act. Patients and families should be involved in decision making process. (Tracey 2014). These decisions should be communicated to primary care. Aims: To assess practice of discussions of DNACPR decisions with patients & family; consultant review of decisions & communication with primary care. Method: Retrospective review of COPD admission notes in North Bristol Trust between 1st February – 30th April 2014 (N=91). Existing community DNACPR were excluded (N=2) Results: 23.5% had hospital DNACPR forms completed. There were 4 deaths. 86% were completed by a junior doctor. Consultants reviewed 83% of decisions, 61% 100% not discussed with patient were discussed with family. No DNACPR decision was recorded on discharge summary. Discussion: There was good compliance with legal duty to discuss with patient. The majority not discussed were due to patient being too unwell. There is a disparity, however, when communicating with primary care, with none communicated on discharge summary. Discharge summary template has been adjusted to improve this.

Recent years have seen marked improvements in end-of-life care, however end-of-life care in Korea has been focused mostly on cancer patients. Thus, this review focuses on understanding the needs of end-of-life care for older adults with terminal chronic illness. A literature review synthesized the qualitative and quantitative evidence on end-of-life care for older adults with terminal chronic illness in Korea. A literature search pertaining to older adults and hospice/palliative/end-of-life care was conducted using electronic databases from January 1990 to July 2013 to cover published research in health and social science. Studies that focused of death or resuscitation decisions were excluded. Each study selected was screened independently by two investigators. A narrative synthesis was used. Twenty-three studies were included in the review. Results suggest that research on end-of-life care for older adults with terminal chronic illness is limited to developing intervention for older adults with terminal chronic illness. Therefore, more research is required on the needs of older adults entering the terminal phase of chronic illness to assist in developing intervention for those with terminal chronic illness as well as their caregivers.

Background Decisions regarding Cardio-Pulmonary Resuscitation (CPR) and Do Not Attempt Resuscitation (DNAR) orders remain demanding, as does including patients in the process. Objectives To explore physicians’ justification for CPR/DNAR orders and decisions regarding patient inclusion, as well as their reports of how they initiated discussions with patients. Methods We administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. Results Justifications were provided for 59% of DNAR orders and included severe comorbidity, patients and families’ resuscitation preferences, patients’ age, or poor prognosis or quality of life. Reasons to include patients in CPR/DNAR decisions were provided in 96% and 84% of cases, and were based on respect for autonomy, clinical assessment of the situation as not too severe, and the view that such inclusion was required. Reasons for not including patients were offered in 84% of cases for CPR and in 70% for DNAR. They included absent decision-making capacity, a clinical situation viewed as good (CPR) or offering little hope of recovery (DNAR), barriers to communication, or concern that discussions could be emotionally difficult or superfluous. Decisions made earlier in the patient9s management were infrequently viewed as requiring revision. Residents reported a variety of introductions to discussions with patients. Conclusions These results provide better understanding of reasons for CPR/DNAR decisions, reasons for patient inclusion or lack thereof, and ways in which such inclusion is initiated. They also point to potential side-effects of implementing CPR/DNAR recommendations without in-depth and practical training. This should be part of a regular audit and follow-up process for such recommendations.

Aim This study assessed the level of agreement on CPR decisions among intensive care doctors and specialist physicians and surgeons, and the barriers to documenting do not attempt resuscitation (DNAR) orders for ward patients during Medical Emergency Team (MET) calls. Methods We prospectively assessed all patients having MET calls for 11 months. If the intensive care doctor on the MET considered a DNAR order appropriate for the patient, the primary care clinician was contacted to: (1) confirm agreement or disagreement with a DNAR order and (2) give reasons as to why a DNAR order was not considered or documented prior to the MET call. Results In the study period, the MET attended 1458 patients. A DNAR order was considered appropriate in 129 cases. In 116 (90%), the primary care clinician agreed with a DNAR order at the time of the MET. Common reasons given by primary care clinicians for not documenting DNAR orders included acute or unexpected deterioration (22.5%), awaiting family discussion (22.5%), actively treating the patient for a reversible condition (17.1%), not knowing the patient well enough (10.9%) and resuscitation status not yet discussed by team (10.9%). Conclusions This study shows a high level of agreement on DNAR orders among intensive care doctors, physicians and surgeons for deteriorating ward patients. Barriers to timely documentation need to be addressed. Delay in documentation and communication of DNAR orders is common. The MET system provides an opportunity to identify patients for whom a DNAR order should be considered.

This study examined whether biases concerning age and/or disability status influenced resuscitation decisions. Medical students were randomly chosen to read 1 of 4 vignettes, organized in a 2 (age: infant vs school-age) × 2 (disability: preexisting vs no preexisting) between-subjects design. The vignettes described a pediatric patient experiencing an acute episode who required resuscitation. Following resuscitation, patients with existing disability would continue to have disability, whereas those without would develop disability. Participants indicated whether they would resuscitate, given a 10% chance of success. There was a significant main effect of disability: Medical students displayed a preference for resuscitating previously disabled children compared with previously healthy children when prognosis was held constant, F(1, 121) = 4.89, p = .03. This differential treatment of the two groups cannot easily be morally justified and poses a quandary for educators.

SummarySurvival to discharge after in-hospital cardiopulmonary resuscitation (CPR) is about 20% in those aged 65–69 years, declining with advancing age to about 10% in those aged 90 years or more. There are conflicting reports on whether or not advanced age, independent of the severity of acute and chronic illness, is a determinant of outcome. Recognition that the outcome of CPR in hospital patients is often poor has prompted extensive debate regarding the appropriate use of this procedure. In particular, there has been concern about unnecessary CPR in extended-care and hospice settings. Conversely, there has also been evidence that doctors and families may be prone to underestimate the quality of life and likelihood of benefit from CPR in older people and to make resuscitation decisions without considering the preferences of older people themselves. Recent guidelines have attempted to strike a balance between ensuring patient participation whenever possible but without offering illusory choices where CPR is very unlikely to succeed.

There has been a dramatic change in the way that resuscitation decisions are made for older hospital inpatients in the UK. In less than 20 years many geriatric medicine wards have moved from an “opt-in” policy (where the default position is not to provide resuscitation) to a position where resuscitation is widely available to older patients and clinicians are much more reluctant to make “do not attempt cardiopulmonary resuscitation” decisions on medical grounds alone. The drivers for this change are rooted in societal changes rather than scientific or legal advances. Older patients are increasingly educated and have higher expectations of health care, while doctors are more commonly criticised and have progressively less “power” in the doctor–patient relationship. Doctors in the UK are struggling with the growing volume and complexity of guidelines about resuscitation, which can prove very tricky to enact within current resources and priorities. Many are feeling stressed and under equipped to cope with the ethical and legal dilemmas of resuscitation decision making. The solution lies in better undergraduate and postgraduate training which enhances skills (such as consultation skills and ethical reasoning) and not just knowledge of laws, principles and guidelines.

Objective To determine the factors considered most important by emergency physicians when deciding to institute or withhold resuscitation in a hypothetical patient with a life-threatening illness. Method A self-administered questionnaire containing a clinical scenario was posted to all Victorian emergency physicians in April 1997. Respondents were asked to decide between intubation and no active treatment, to rate the importance of various factors in making this decision and to rate the likelihood of altering the decision given hypothetical changes in the scenario. Results The response rate was 67% (46/69). Of those choosing intubation (89%), most would have changed the decision if the patient had dementia, was permanently bed-bound or was totally dependent for activities of daily living. Decisions were most influenced by reversibility of the illness, the patient's functional state and the perceived quality of life. Conclusion Emergency physicians consider many factors when deciding whether or not to actively resuscitate patients. Further study of the decision making process is recommended.

Purpose In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions. Materials and Methods Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes. Results Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P P = .5). Conclusions Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.

The decision to perform cardiopulmonary resuscitation (CPR) remains one of the most important and difficult decisions a physician must make. This study examined differences in CPR decision making among senior hospital clinicians. A questionnaire was sent out to consultants and specialist registrars in general medicine, elderly care and intensive care in a large UK district general hospital, with anonymous returns. Short clinical scenarios were presented, and participants stated their CPR decision and their confidence level. In total, 86 questionnaires were sent out and 54 replies (63%) were received. There were significant differences between specialties in making the decision to perform CPR and the confidence in doing so, with three cases producing polarised results within the specialties, despite equal confidence in the decision. There is lack of consensus with the CPR decisions made between specialties and within them. Formal training in recognition of futility should be encouraged for all clinicians.

Summary Background and objective Cardiopulmonary resuscitation is undertaken more than 250,000 times annually in the United States. This study was undertaken to determine knowledge and opinions of the general public regarding cardiopulmonary resuscitation. Design Validated multisite community-based cross-sectional survey. Outcome measures Knowledge and opinions about resuscitative practices and outcomes, using hypothetical clinical scenarios and other social, spiritual, and environmental considerations. Results Among 1831 participants representing 38 states, markedly inaccurate perceptions of cardiac arrest were reported. Participants’ mean estimate of predicted survival rate after cardiac arrest was 54% (median 50%, IQR 35–75%), and mean estimated duration of resuscitative efforts in the ED was 28 min (median 15 min; IQR 10–30). Projected age and health status were independent predictors of resuscitation preferences in a series of 4 hypothetical scenarios. Participants indicated that physicians should consider patient and family wishes as the most important factors when making resuscitation decisions. Participants considered advanced technology and physician communication to be the most important actions during attempted resuscitation. Conclusions Inaccurate perceptions regarding resuscitation and survival rates exist among the lay public. Participants indicated strong preferences regarding resuscitation and advance directives.

Introduccion La orden de no resucitacion es una medida referida estrictamente a la no realizacion de maniobras de reanimacion cardiopulmonar (RCP), sin embargo se observa que habitualmente implica modificaciones en el tratamiento. Objetivos Analizar el efecto que tiene la orden de no RCP en el plan de atencion al paciente critico y analizar si existen diferencias en la carga de trabajo de enfermeria ( Nine Equivalents of Nursing Manpower Use Score [NEMS]) antes y despues de la orden de no RCP. Metodo Este estudio descriptivo analizo el plan de atencion de 50 pacientes criticos antes y despues de la orden electronica de no RCP. Resultados Las variaciones encontradas despues de la firma de la orden de no RCP fueron la retirada de tratamientos en 30 pacientes, la instauracion en 6, en 12 tanto se retiraron como se iniciaron tratamientos y en 2 no hubo cambios. Se encontraron modificaciones en el soporte ventilatorio, en la administracion de farmacos vasoactivos y en la depuracion extrarrenal. Soporte ventilatorio: a 7 pacientes se les retiro la ventilacion invasiva, a 3 la ventilacion no invasiva y a 15 se les disminuyo la fraccion inspiratoria de oxigeno del respirador el dia del exitus . Farmacos vasoactivos: en 10 pacientes se retiro el tratamiento vasoconstrictor y en uno se instauro, los inotropicos se retiraron en 3 pacientes y se instauraron en 2. Depuracion extrarrenal: en 4 pacientes se retiro y en 2 se inicio. La puntuacion NEMS disminuyo despues de la orden (36,20-34,62; p = 0,030). Conclusiones La orden de no RCP tiene un efecto en el plan de atencion al paciente critico. Por otro lado, aunque la puntuacion NEMS disminuye ligeramente despues de la firma, la carga de trabajo de enfermeria se mantiene al incrementarse la atencion psicosocial al paciente y a la familia.

PurposeThe purpose of this article is to assess important recent guidelines on resuscitation, published in December 2005.Design/methodology/approachThe guidelines are put into the context of other attempts to standardise CPR practice. An analysis of recent claims and complaints handled by the Medical Protection Society and problems reported to the National Patient Safety Agency, broadens the discussion.FindingsA number of issues of concern arose – the competence of health professionals, recognising the deterioration of patients, communication of Do Not Attempt Resuscitation decisions, and equipment failings. Strengthening training, better monitoring and performance management are important in addressing these issues.Practical implicationsHealth professionals have a good opportunity to avail themselves of the new CPR guidelines; it is in the public interest to try and achieve these standards.Originality/valueThe paper highlights the continuing risks in providing substandard resuscitation.

The imminent birth of an extremely premature infant presents parents and health care professionals with difficult decisions regarding how aggressively to provide treatment for the infant. These dilemmas exist because extremely premature infants are at risk for disabilities such as cerebral palsy, blindness, and other neurological disorders. Technology has facilitated improved survival rates, but outcomes are uncertain and cannot be reliably predicted. The essential questions with the birth of an extremely preterm infant are: should the infant be resuscitated, and who makes the decision to resuscitate? This paper will explore resuscitation decisions for the extremely preterm infant within the social model of disability.

Talking to patients about ‘Do Not Attempt Resuscitation’ decisions is difficult for many doctors. Communication about ‘Do Not Attempt Resuscitation’ decisions should occur as part of a wider discussion of treatment goals at an earlier stage in the patient's illness. A doctor should not initiate any treatment, including cardio-pulmonary resuscitation if he/she does not believe it will benefit the patient. An ethical framework is offered which may be of practical help in clarifying decision-making. British Journal of Cancer (2002) 86, 1057–1060. DOI: 10.1038/sj/bjc/6600205 www.bjcancer.com © 2002 Cancer Research UK

Doctors are often reluctant to start conversations about resuscitation decisions. In four articles The BMJ squares up to decisions on “Do not attempt cardiopulmonary resuscitation” (DNACPR), to spark debate about an area of clinical practice often fraught with legal and ethical challenges. Zoe Fritz and colleagues describe how doctors are hesitant to raise DNACPR in case it distresses patients or leads to a complaint (doi:10.1136/bmj.j813; doi:10.1136/bmj.j876). But patients rarely start this conversation either, even though research shows that many older …

Background: Most patients dying at home do not have a Do Not Attempt Cardiopulmonary Resuscitation decision and may have inappropriate attempts at resuscitation made when they die. Aim: To investigate how general practitioners think and feel about making and communicating Do Not Attempt Cardiopulmonary Resuscitation decisions for patients dying in the community. Design: Qualitative study using semi-structured interviews with general practitioners. The interviews were recorded and analysed using interpretative phenomenological analysis. Setting/participants: Purposive sampling was used to recruit 10 general practitioners from urban and rural practices in Southern England and of various ages and experience. Interviews were carried out either in their home or in their practice. Results: General practitioners often wait until the patient has clearly deteriorated to communicate and document the Do Not Attempt Cardiopulmonary Resuscitation decision. They consider the chance of success of a resuscitation attempt, quality of life, dignity and the patient’s and family’s wishes. General practitioners feel they should discuss the decision with the patient but have anxieties about this. They vary widely in how much they guide patients and families in decision-making. Timing and the avoidance of conflict are important. Teamwork provides support in decision-making. Conclusion: Resuscitation decisions are important in facilitating a peaceful death, but can be difficult for general practitioners to discuss. General practitioners might benefit from clearer guidance on when an attempt at resuscitation is unlikely to be successful, especially in non-malignant disease. Team discussions including Gold Standards Framework meetings can give confidence and support in making difficult end-of-life decisions.

OBJECTIVE: To characterize physician–parent counseling and delivery room resuscitation of extremely low birthweight (ELBW) infants. STUDY DESIGN: Cross-sectional survey of 473 California neonatologists detailing counseling patterns, resuscitation thresholds, and acceptance of parental decision making. RESULTS: The response rate was 61%. After 23 weeks' gestation, >80% of neonatologists counseled parents expecting ELBW infants. All (>99%) counseled parents about mortality; >25% reported not discussing limiting resuscitation or death despite resuscitation. Decisions to limit resuscitation were affected by congenital anomalies, parents' wishes, or perceptions of pain, suffering, and quality of life. Nearly 70% of neonatologists supported parental decision making at 22 to 23 weeks, whereas 66% to 74% responded that parents should not be allowed to make nonresuscitation decisions after 26 weeks. Median resuscitation thresholds were 23 weeks (range 20–28) and 500 g (range 350–1000). CONCLUSIONS: Neonatologists' failure to discuss nonresuscitation options, variations in resuscitation thresholds, and unwillingness to accept nonresuscitation decisions for more mature ELBW infants may restrict parental decision making.

This article provides the reader with a historical perspective of advance directives, the role of surrogate decision making, and the difficulties families encounter surrounding end-of-life decisions. Illustrated with a case study, it includes a framework for advanced practice nurses (APNs) and other health care professionals to assist families in reaching decisions. The APN can be instrumental in initiating an ethical discussion about resuscitation decisions and assist in dealing with conflicts. The APN can strive to make Do Not Resuscitate (DNR) discussions a consistent part of the hospital experience. It is hoped that the use of such a framework will improve care at the end of life.

When do not attempt resuscitation orders are contemplated, guidelines exist to outline standards for planning patient care and decision making. These guidelines may not always be fully followed as ethical issues arise which may prevent doctors from doing so.

Background Recent years have seen marked improvements in end-of-life care, however concerns have been expressed that services are focused on the needs of patients with cancer. This review focuses on conversations about end-of-life care with frail and older people who have no main overriding diagnosis who are estimated to account for around 40% of deaths. Aim To investigate the attitudes of the public and healthcare professionals to advance care planning discussions with frail and older people. Design and setting Systematic literature review and narrative synthesis. Method Articles that related to frail or older individuals and either advance care plans or discussions on end-of-life care were included. Studies of specific conditions or that focused on prognosis, capacity, or resuscitation decisions were excluded. Results While a significant minority of frail older individuals would find them unwelcome, the majority would appreciate the chance to discuss end-of-life care, yet most do not have this opportunity. Attitudes to the timing of these discussions were variable, but most perceived the risk of leaving them too late. Most doctors believed it was their professional responsibility to initiate discussions, but felt limited by time pressures and the absence of a precipitating event. A wide range of barriers were identified including the reluctance of family members to discuss end-of-life care, the passive expectation that someone else would decide on an individual’s behalf, and significant uncertainty concerning future illness and decline. Conclusion The marked disparity between the majority of older individuals who would like the opportunity to discuss their end-of-life care and the minority that currently have this opportunity raises important questions if the wishes of this large group in society are to be respected. The challenge is to find effective ways of encouraging dialogue and choice within the constraints of the current healthcare systems and personal circumstances.

Discussing, making and documenting do-not-attempt-resuscitation (DNACPR) decisions can be challenging. Problems highlighted by qualitative and quantitative1 research include: misinterpreting DNACPR decisions, resulting in withholding of other treatments; poorer care for those with DNACPR decisions than for similar patients without; inconsistent CPR decision-making; too many futile or unwanted CPR attempts; different ways of recording CPR decisions; and reluctance of patients and doctors to discuss CPR.