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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.

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 People with intellectual disabilities experience significant health inequities. The aim of this report is to understand the circumstances leading to death from COVID‐19 in people with intellectual disabilities. Method Local areas in England prioritised reviewing 200 deaths of adults with intellectual disabilities. Of these, approximately 80% were required to be deaths from suspected or confirmed COVID‐19 as this was the focus of the study; the remainder from other causes. All deaths occurred between 2 March2020 and 9 June 2020. Results People with intellectual disabilities differed from the general population in their symptoms of COVID‐19 and age at death. The overall quality of care was rated similar to other deaths of people with intellectual disabilities. Concerns were raised relating to recognising acute deterioration and do not attempt cardio‐pulmonary resuscitation decisions. Conclusions Service improvements are indicated in the ways in which people with intellectual disabilities encounter COVID‐19 and experience the disease.

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.

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 …

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.

IntroductionTreatment escalation plans (TEPs) are important to ensure that every patient has their ceiling of care discussed and documented formally. At Medway Foundation Trust, we introduced TEP forms in September 2016 which are to be completed by the relevant consultant within 24 hours of admission.Aims and methodsTo evaluate whether TEP forms had been effective at improving escalation planning and whether they had a subsequent impact in do not attempt cardiopulmonary resuscitation (DNACPR) decision-making. We carried out three plan-do-study-act cycles over a 2-year period across 100 patients in medicine and surgery.ResultsTEP forms were initially found in 66% (66/100) of the patient notes and 34% (34/100) were completed appropriately. There was a 13% relative improvement in resuscitation decision-making, since the introduction of the TEP forms from November 2015 to January 2017. There was also a 12% reduction in inappropriate referrals to critical care during the same period. We decided to revise the TEP form through extensive collaboration and educate all staff members about the importance of escalation planning. This has led to an improvement in TEP discussion and documentation across the entire trust.ConclusionTEPs can be an effective way of considering and communicating ceilings of care. They should encourage doctors to consider DNACPR decisions for patients who otherwise would not have been considered, and therefore may help reduce inappropriate referrals to critical care. The higher completion rates of the new form and increased clarity among staff regarding escalation planning should lead to an improvement in patient safety outcomes and communication between all patients and staff members. We believe it would be feasible to implement our user-friendly TEP form across other National Health Service organisations in order to develop a universal TEP form.

Purpose of the study\ud \ud Variation in the recording of DNACPR decisions between healthcare organisations creates policy and communication challenges when patients are transferred between organisations. A recent UK stud y identified the need for a nationwide system to record resuscitation decisions alongside other treatment escalation decisions. The development of the UK - based Recommended Summary for Emergency care and Treatment Plan (ReSPECT) process was a response to this need. ReSPECT has been available to healthcare organisations to adoption since Spring 2017. The purpose of this study was to record current variation in the way in which DNACPR decisions are recorded in UK hospitals and identify the current uptake of the ReSPECT process. \ud \ud Materials and methods\ud \ud We conducted an online survey between October 2017 and March 2018 of all UK adult NHS hospitals participating in the National Cardiac Arrest Audit (NCAA). Descriptive statistics were used to report the results. \ud \ud Results \ud \ud Of the 187 hospitals surveyed, 114 (61%) responded. Most hospitals reported using a DNACPR form (n=57, 50%). Other hospitals used either a DNACPR form with separate treatment escalation plan (n=35, 31%), an ECTP or DNACPR form combined with a treatment escalation plan (n=20, 18%), or another system (n=2, 2%). In total, 8 hospitals (7%) were using the ReSPECT system. \ud \ud Conclusions\ud \ud There is variation in the way in which DNACPR decisions are recorded in UK hospitals. To date, only a small number of hospitals have implemented the ReSPECT process \ud

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.

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.

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.

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.

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.

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 …

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.

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.

Background: The survival rate of out-of-hospital cardiac arrest (OHCA) victims in Lebanon is low. A national policy on resuscitation practice is lacking. This survey explored the practices of emergency physicians related to the resuscitation of OHCA victims in Lebanon. Methods: A sample of 705 physicians working in emergency departments (EDs) was recruited and surveyed using the LimeSurvey software (Carsten Schmitz, Germany). Seventy-five participants responded, yielding 10.64% response rate. Results: The most important factors in the participants’ decision to initiate or continue resuscitation were presence of pulse on arrival (93.2%), underlying cardiac rhythm (93.1%), the physician’s ethical duty to resuscitate (93.2%), transport time to the ED (89%), and down time (84.9%). The participants were optimistic regarding the survival of OHCA victims (58.1% reporting > 10% survival) and reported frequent resuscitation attempts in medically futile situations. The most frequently reported challenges during resuscitation decisions were related to pressure or presence of victim’s family (38.8%) and lack of policy (30%). Conclusion: In our setting, physicians often rely on well-established criteria for initiating/continuing resuscitation; however, their decisions are also influenced by cultural factors such as victim’s family wishes. The findings support the need for a national policy on resuscitation of OHCA victims.

It is disheartening to see a dignified death sabotaged by an ill considered attempt at resuscitation.1 Herein lies the problem—how many patients on palliative care registers actively have their resuscitation status considered? Hospitals make resuscitation decisions on all their patients, yet patients who are not for resuscitation in hospital can be discharged …

Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.

To examine influences on neonatologists' decision-making regarding resuscitation of extremely premature infants. A mailed survey of Illinois neonatologists evaluated influences on resuscitation. Personal and parentally opposed (that is, acting against parental wishes) gray zones of resuscitation were defined, with the lower limit (LL) the gestational age at or below which resuscitation would be consistently withheld and the upper limit (UL) above which resuscitation was mandatory. Among the 85 respondents, LL and UL of the personal and parentally opposed gray zones were median 22 and 25 weeks, respectively. Neonatologists with an UL personal gray zone

A legal case last year resulted in changes to the law on patient involvement in resuscitation decisions. Zac Etheridge and Emma Gatland set out the implications for doctors and hospitals

Background: Recent cultural changes place doctors under increasing pressure to work with their patients to reach decisions about end-of-life care. Aim: To survey the experience, practice and opinions of specialist registrars (SPRs) in geriatric medicine regarding ‘do not attempt resuscitation’ (DNAR) decisions. Design: Postal questionnaire survey. Methods: A questionnaire was mailed to all members registered as trainees ( n = 408) with the British Geriatrics Society in November 2003; a reminder was sent nine weeks later. Responses were analysed using both quantitative and qualitative (thematic) approaches. Results: Response rate was 62% (251/408), of whom 235 were still SpRs. Respondents played a major role in DNAR decision-making in their day-to-day clinical practice. Over a third of respondents did not feel that locally available guidelines were helpful. More than half sometimes disagreed with their consultants’ decision, and a fifth were concerned about the possibility of complaints regarding the decisions they made. The majority felt uncomfortable discussing the issue with the patient, and were more likely to discuss the issue with relatives than with patients. Discussion: Further support and training may improve confidence and positive experiences in relation to DNAR decision-making among training-grade doctors in the UK.

Geriatricians are often asked to make decisions about withholding cardiopulmonary resuscitation. This seems to be becoming more difficult and more controversial. There has been increased public concern about this subject recently and a recognition within the profession of the need for more openness and transparency in decision making. The implementation of The Human Rights Act led to updated guidelines from professional bodies, but these are likely to need careful interpretation in light of local circumstances before they can become a practical tool for decision making.

Hospital consultants are still not involved in the vast majority of “do not resuscitate” (DNR) orders despite national guidelines, according to a new report. A team of consultants and specialists registrars who reviewed the performance at one London hospital also found that the decision making process leading up to such orders was poorly documented and that there was …

Decisions about cardiopulmonary resuscitation may be based on medical prognosis, quality of life and patients' choices. Low survival rates indicate its overuse. Although the concept of medical futility has limitations, several strong predictors of non-survival have been identified and prognostic indices developed. Early results indicate that consideration of resuscitation in the elderly should be very selective, and support "opt-in" policies. In this minority of patients, quality of life is the principal issue. This is subjective and best assessed by the individual in question. Patients' attitudes cannot be predicted reliably and surrogate decision-making is inadequate. Lay knowledge is poor. However, patients can use prognostic information to make rational choices. The majority welcome discussion of resuscitation and prefer this to be initiated by their doctors; many wish to decide for themselves. There is little evidence that this causes distress. The views of such patients, if competent, should be sought actively.

A man plans to sue England’s health secretary, Andrew Lansley, and a hospital trust for allegedly imposing a “do not attempt to resuscitate” order on his wife without her express consent. David Tracey is taking legal action against Cambridge University Hospitals NHS Foundation Trust for allegedly failing to carry out cardiopulmonary resuscitation on his wife, Janet. He claims that the trust and the Department of Health for England acted unlawfully by not having a standard policy on resuscitation decisions. Mrs Tracey, who …

This is the third discussion topic in a series of five dealing with ethical, professional, and legal obligations of clinical practice. Junior doctors tend to lack confidence in these subjects, and thus I organised a series of informal discussions in our surgical unit on which these articles are based. The sessions were prepared with reference to non-academic literature readily available from the General Medical Council and the medical defence organisations. While our unit dealt with these issues from a surgical perspective, the obligations of clinical practice apply to all practitioners, and the series could be easily modified for other clinical specialties. Closed chest resuscitation for cardiopulmonary arrest was pioneered in the 1960s and a crash team is now a standard feature of UK acute hospitals.1 Different series report survival rates ranging from 5%–20%. A “not for resuscitation” (NFR) decision indicates that an elective decision has been made not to call the crash team if in the future that patient stops breathing or suffers cardiac arrest. Resuscitation decisions are very emotive and have been the subject of much media interest. Every …

EDITOR—I was not surprised to see that national guidelines on resuscitation decisions are being ignored.1 I have worked in several hospitals on acute medical wards and often have seen fudged resuscitation decisions. I believe that the decision on resuscitation should, as with any treatment, be made by the patient first. If the patient is unable or too ill to make the decision it should be made in consultation with …