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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 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.

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.

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.

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.