Zoë Fritz

Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation.

UNLABELLED Most people who die in hospital do so with a DNACPR order in place, these orders are the focus of considerable debate. AIM To identify factors, facilitators and barriers involved in DNACPR decision-making and implementation. METHODS All study designs and interventions were eligible for inclusion. Studies were appraised guided by CASP tools. A qualitative analysis was undertaken. DATA SOURCES Included electronic databases: Medline, Embase, ASSIA, Cochrane library, CINAHL, PsycINFO, Web of Science, the Kings Fund Library and scanning reference lists of included studies. RESULTS Four key themes were identified: Considering the decision - by senior physicians, nursing staff, patients and relatives. Key triggers included older age, co-morbidities, adverse prognostic factors, quality of life and the likelihood of success of CPR. Discussing the decision - levels, and combinations, of physician and nursing skills, patient understanding and family involvement produced various outcomes. Implementing the decision - the lack of clear documentation resulted in a breakdown in communications within health teams. Staff knowledge and support of guidelines and local policies varied. Consequences of a DNACPR decision - inadequate understanding by staff resulted in suboptimal care, and incorrect withdrawal of treatment. CONCLUSION Significant variability was identified in DNACPR decision-making and implementation. The evidence base is weak but the absence of evidence does not indicate an absence of good practice. Issues are complex, and dependent on a number of factors. Misunderstandings and poor discussions can be overcome such as with an overall care plan to facilitate discussions and reduce negative impact of DNACPR orders on aspects of patient care.

Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects

Since their introduction as ‘no code’ in the 1980s and their later formalisation to ‘do not resuscitate’ orders, such directions to withhold potentially life-extending treatments have been accompanied by multiple ethical issues. The arguments for when and why to instigate such orders are explored, including a consideration of the concept of futility, allocation of healthcare resources, and reaching a balance between quality of life and quality of death. The merits and perils of discussing such decisions with patients and/or their relatives are reviewed and the unintended implications of ‘do not attempt resuscitation’ orders are examined. Finally, the paper explores some alternative methods to approaching the resuscitation decision, and calls for empirical evaluation of such methods that may reduce the ethical dilemmas physicians currently face.

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

Aims To determine whether the introduction of the Universal Form of Treatment Options (the UFTO), as an alternative approach to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, reduces harms in patients in whom a decision not to attempt cardiopulmonary resuscitation (CPR) was made, and to understand the mechanism for any observed change. Methods A mixed-methods before-and-after study with contemporaneous case controls was conducted in an acute hospital. We examined DNACPR (103 patients with DNACPR orders in 530 admissions) and UFTO (118 decisions not to attempt resuscitation in 560 admissions) practice. The Global Trigger Tool was used to quantify harms. Qualitative interviews and observations were used to understand mechanisms and effects. Results Rate of harms in patients for whom there was a documented decision not to attempt CPR was reduced: Rate difference per 1000 patient-days was 12.9 (95% CI: 2.6–23.2, p-value = 0.01). There was a difference in the proportion of harms contributing to patient death in the two periods (23/71 in the DNACPR period to 4/44 in the UFTO period (95% CI 7.8–36.1, p-value = 0.006). Significant differences were maintained after adjustment for known confounders. No significant change was seen on contemporaneous case control wards. Interviews with clinicians and observation of ward practice revealed the UFTO helped provide clarity of goals of care and reduced negative associations with resuscitation decisions. Conclusions Introducing the UFTO was associated with a significant reduction in harmful events in patients in whom a decision not to attempt CPR had been made. Coupled with supportive qualitative evidence, this indicates the UFTO improved care for this vulnerable group. Trial Registration Controlled-Trials.com ISRCTN85474986 UK Comprehensive Research Network Portfolio 7932

Resuscitation policy should focus on the patient, not the decision

Zoë Fritz and colleagues discuss new approaches to resuscitation decisions that incorporate broader goals of care

Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions.

BACKGROUND The treatment for a cardiac arrest, cardiopulmonary resuscitation (CPR), may be lifesaving following an acute, potentially reversible illness. Yet this treatment is unlikely to be effective if cardiac arrest occurs as part of the dying process towards the end of a persons natural life. Do not attempt CPR (DNACPR) decisions allow resuscitation to be withheld when it has little chance of success, or where the patient, or those close to the patient, indicate the burdens of CPR outweigh the benefits. This review sought to identify evidence for systems that improve the appropriate use of DNACPR decisions. METHODS Electronic databases were searched (Medline, CINAHL and Embase) for English language articles from 2001 to 2014. RESULTS 4090 citations were identified of which 37 studies were relevant. The overall quality of evidence was moderate to poor. Thematic synthesis identified key interventions which may improve DNACPR decision making. The most promising interventions involved structured discussion at the time of acute admission to hospital and review by specialist teams at the point of an acute deterioration. Linking DNACPR decisions to discussions about overall treatment plans provided greater clarity about goals of care, aided communication between clinicians and reduced harms. Standardised documentation proved helpful for improving the frequency and quality of recording DNACPR decisions. Patient and clinician education in isolation were associated with limited or no effects. CONCLUSION Relatively simple process changes may enhance the appropriate use of and outcomes associated with DNACPR decisions. Systematic review registration number: PROSPERO2012:CRD42012002669.

Medical oaths and declarations

The newly qualified doctors of Imperial College School of Medicine recently adopted a ceremony in which they declare their commitment to assume the responsibilities and obligations of the medical profession. The decision to create a declaration ceremony was widely supported by the final year students and it reflects a recent resurgence in interest in medical oaths in the United Kingdom. 1 2 Some 98% of American 1 3 and nearly 50% of British medical students 1 4 swear some kind of oath, either on entry to medical school5 or at graduation.4 One reason why oaths are more common in America may be that American children are brought up to swear their allegiance to the flag, so the concept of affirming their beliefs is less alien than to British students. Oaths are neither a universal endeavour 3 4 nor a legal obligation, and they cannot guarantee morality. So why should doctors take an oath at all? In 1992 a BMA working party found that affirmation may strengthen a doctors resolve to behave with integrity in extreme circumstances. This group recommended that …

Documentation of resuscitation decision-making: A survey of practice in the United Kingdom

UNLABELLED Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders have been in use since the 1990s. The Resuscitation Council UK (RCUK) provides guidance on the content and use of such forms in the UK but there is no national policy. AIM To determine the content of DNACPR forms in the UK, and the geographical distribution of the use of different forms. METHODS All acute trusts within the United Kingdom were contacted via a combination of email and telephone, with a request for the current DNACPR form along with information about its development and use. Characteristics of the model RCUK DNACPR form were compared with the non-RCUK DNACPR forms which we received. Free text responses were searched for commonly occurring phrases. RESULTS 118/161 English NHS Acute Trusts (accounting for 377 hospitals), 3/6 Northern Irish NHS Acute Trusts (accounting for 25 hospitals) and 3/7 Welsh Health Boards (accounting for 73 hospitals) responded. All Scottish hospitals have the same form. All responding trusts had active policies and have a DNACPR form in use. 38.9% of respondent hospitals have adopted the RCUK form with minor amendments. The remainder of the responding hospitals reported independent forms. 66.8% of non-RCUK forms include a transfer plan to ambulance staff and 48.4% of non-RCUK forms are valid in the community. Several independent trusts submitted DNACPR forms with escalation plans. CONCLUSIONS There is wide variation in the forms used for indicating DNACPR decisions. Documentation is rapidly evolving to meet the needs of patients and to respond to new evidence.

Development of the Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a cross‐disciplinary approach

Rationale aims and objectives Problems exist with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: they are often misinterpreted by clinicians to mean that other treatments should be withheld; resuscitation decision discussions are difficult; patients remain inappropriately for resuscitation. We developed an alternative approach. Methods An adapted Delphi method was used. Senior clinicians were interviewed about the strengths and weakness of current practice. Teams who had initiated alternative approaches internationally were contacted. Focus groups were conducted with doctors, nurses and patients to further understand problems with DNACPR orders and establish essential aspects of a new approach. A behavioral economist and management consultant contributed advice. The resulting form was recirculated and further refined. It was: snowballed out to others with specialist expertise (palliative care physicians, intensivists, etc) for further feedback; assessed in simulated clinical encounters before being piloted; further adjusted once in clinical practice. In parallel, a patient information leaflet was developed along with education materials. Results Consensus was achieved that the new approach should: be universal; have discussions and clinical conditions documented first; clarify goals of overall treatment (active treatment or optimal supportive care); contextualize the resuscitation decision among other treatment decisions; have a free text box for ‘opting out’ of invasive treatments, rather than tick boxes; be green; be limited to one page. Conclusions The Universal Form of Treatment Options was developed iteratively with patients, doctors and nurses as an alternative approach to resuscitation decisions. This paper illustrates a cross-disciplinary approach to developing practical alternatives in health care.

Emergency care and resuscitation plans

#### What you need to know When a person’s heart or breathing stops and the cause is reversible, immediate cardiopulmonary resuscitation (CPR) offers a chance of life. However, when a person is dying—for example, from organ failure, frailty, or advanced cancer—and his or her heart stops as a final part of a dying process, CPR will not prevent death and may do harm. “Do not attempt CPR” (DNACPR) decisions were first documented in the 1970s, to try to protect people from receiving CPR that they did not want, that would not work, or would not give them overall benefit. This approach of making CPR decisions separately from decisions about other treatments has been challenging for clinicians and patients and has caused problems.1 2 3 4 Despite national guidance in the UK (see “Further educational resources” box), misunderstandings, poor communication, and inconsistent DNACPR documentation persist.4 Exploring and achieving a shared understanding among patient, family, and healthcare team of realistic and individualised care preferences may sometimes be done badly or not even attempted. Here we draw on evidence (box 1), collated for a broader project, to outline how clinicians might plan with their patients. We offer suggestions on how clinicians and their patients might better think ahead, consider, discuss and record patient-centred recommendations, not only about CPR but also other elements of emergency care …

Should non-disclosures be considered as morally equivalent to lies within the doctor–patient relationship?

In modern practice, doctors who outright lie to their patients are often condemned, yet those who employ non-lying deceptions tend to be judged less critically. Some areas of non-disclosure have recently been challenged: not telling patients about resuscitation decisions; inadequately informing patients about risks of alternative procedures and withholding information about medical errors. Despite this, there remain many areas of clinical practice where non-disclosures of information are accepted, where lies about such information would not be. Using illustrative hypothetical situations, all based on common clinical practice, we explore the extent to which we should consider other deceptive practices in medicine to be morally equivalent to lying. We suggest that there is no significant moral difference between lying to a patient and intentionally withholding relevant information: non-disclosures could be subjected to Boks ‘Test of Publicity’ to assess permissibility in the same way that lies are. The moral equivalence of lying and relevant non-disclosure is particularly compelling when the agents motivations, and the consequences of the actions (from the patients perspectives), are the same. We conclude that it is arbitrary to claim that there is anything inherently worse about lying to a patient to mislead them than intentionally deceiving them using other methods, such as euphemism or non-disclosure. We should question our intuition that non-lying deceptive practices in clinical practice are more permissible and should thus subject non-disclosures to the same scrutiny we afford to lies.