A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process

Obolensky, Lucy; Clark, Trish; Matthew, G. Douglas; Mercer, M

doi:10.1136/jme.2009.033977

Cited by 36 publications

(47 citation statements)

References 20 publications

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“…21–23 In the current study, survival to discharge fell steeply with increasing neurologic disability at admission, from 39.6% for those with no major disability, 22.6% for those with moderate disability, 19.6% for those with severe disability and 6% for those in a coma or vegetative state. Among patients with baseline neurological deficits, the number of co-existing medical diagnoses did not change survival outcomes.…”

Section: Discussionmentioning

confidence: 40%

Predictors of Survival from Perioperative Cardiopulmonary Arrests

et al. 2013

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Background Perioperative cardio-pulmonary arrests are uncommon and little is known about rates and predictors of in-hospital survival. Methods Using the Get-With-The-Guidelines – Resuscitation national cardiopulmonary resuscitation registry, we identified all patients aged 18 years or older who experienced an index, pulseless cardiac arrest in the operating room or within 24 hours postoperatively. The primary outcome was survival to hospital discharge, and the secondary outcome was neurologically intact recovery among survivors. Multivariable logistic regression models using generalized estimating equation models were used to identify independent predictors of survival and neurologically intact survival. Results There were 2,524 perioperative cardiopulmonary arrests identified from 234 hospitals. The overall rate of survival to discharge was 31.7% (799/2,524), including 41.8% (254/608) for ventricular tachycardia and ventricular fibrillation, 30.5% (296/972) for asystole, and 26.4% (249/944) for pulseless electrical activity. Ventricular fibrillation and pulseless ventricular tachycardia were independently associated with improved survival. Asystolic arrests occurring in the operating room and post-anesthesia care unit were associated with improved survival when compared to other perioperative locations. Among patients with neurological status assessment at discharge, the rate of neurologically intact survival was 64.0% (473/739). Pre-arrest neurological status at admission, patient age, inadequate natural airway, pre-arrest ventilatory support, duration of event and event location were significant predictors of neurological status at discharge. Conclusion Among patients with a perioperative cardiac arrest, 1 in 3 survived to hospital discharge, and good neurological outcome was noted in 2 out of 3 survivors.

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Section: Discussionmentioning

confidence: 40%

Predictors of Survival from Perioperative Cardiopulmonary Arrests

et al. 2013

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“…There was no such reduction in harms in patients with DNACPR orders on other wards during the same time-period, or for patients remaining for CPR, suggesting that the change we observed was due to the use of the UFTO, and not seasonal variation or hospital-wide safety improvements. Accepting that we were looking at a group of patients who have worse outcomes than the standard hospital population, it is worth noting that no previous study of any initiative aimed at improving patient safety (as measured with the GTT) has shown such a profound effect, and that while alternative approaches to recording DNACPR decisions have previously been developed they have not been rigorously assessed for impact upon patient care [18], [19].…”

Section: Discussionmentioning

confidence: 99%

“…While alternative approaches have previously been developed, [18], [19] they have not been applied universally, nor their impact on patient care assessed.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2013

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

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“…In the UK, Treatment Escalation Plans are replacing DNACPR orders in some hospitals (Mercer, ), offering a wider range of treatment options, with an emphasis on how the patient will be managed, rather than what interventions will be with‐held. Initial evaluation suggests that they are positively viewed by patients and families (Obolensky et al ., ). Nevertheless, recent reports published by the UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) highlight inadequacies in end‐of‐life care: the review of services for children's surgery identified that ‘end of life care was absent for those for whom it may have been appropriate’ (NCEPOD, , p.71), whilst the recent review into cardiac arrest outcomes (NCEPOD, ) highlighted a lack of discussion about resuscitation options between health care professional and patient, highlighting the need for a major culture shift.…”

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confidence: 97%