‘Do not resuscitate’ decisions in continuing care psychiatric patients: what influences decisions?

Abstract

Aims and MethodWe evaluated the various aspects of ‘do not resuscitate’ (DNR) decisions taken for psychiatric continuing care patients within NHS Ayrshire and Arran. Records were reviewed and nursing staff were asked their opinions about DNR orders in general and the way these were implemented on their wards.ResultsThere were 35 DNR orders among 88 continuing care patients in mental health wards for older adults. There were no DNR orders for the 25 continuing care patients in general adult psychiatry wards. Quality of life was the main issue when taking a DNR decision. Medical and nursing staff were involved in all decisions and the family in most. Patients were involved in only two cases. The documentation of the DNR order itself was satisfactory but documentation of the reasons behind the decision was inadequate. Patients with DNR status were perceived by ward staff to have more physical debilitation and more dependence on others. Local guidelines were being followed in most aspects, but these needed to be reviewed, as suggested within the resuscitation policy itself.Clinical ImplicationsDecisions not to resuscitate may often be difficult to reach in psychiatric patients. Wards follow heterogeneous policies despite a resuscitation policy existing within the trust. Documentation needs to be improved and medical and nursing staff must reach a consensus regarding what constitutes quality of life and the appropriate time for a DNR decision.

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

“…79,84,85 Sometimes there were less than 24 hours before death, 84,85 with many emergency teams having to decide moments before death whether or not there was a DNACPR order already in place. 66,76,86,90,91 In one Scottish study, 87 consultants on general adult wards and those in old-age psychiatry differed in their opinions about whether or not a DNACPR order should be issued at all: some would discuss this with the family in cases where the patient may live for many more years and others would raise it only if the patient was clearly at the end of his or her life. There were indications that the longer the duration of the stay in hospital the more DNACPR orders were documented, 16 sometimes after a prolonged stay and aggressive therapeutic measures.…”

“…87 There were more DNACPR orders written in acute wards than in planned admissions such as surgical wards. 70 This is illustrated by one study 16 which found more DNACPR orders in acute admissions (n = 99/119) than in planned admissions (n = 20/119; p < 0.05); the most frequently written DNACPR orders came from internal medicine and pulmonology, with fewer from cardiology, thoracic surgery and neurosurgery wards.…”

“…Quality of life was frequently mentioned when making decisions, although the term remained undefined by staff; 87 factors staff considered included poor quality of life of the patient prior to cardiopulmonary arrest and expected quality of life after resuscitation. 72,87,93 Similarly mentioned were terms such as futility, 77,86 withholding potentially harmful treatment 77 and the likelihood of successful CPR.…”

“…72,87,93 Similarly mentioned were terms such as futility, 77,86 withholding potentially harmful treatment 77 and the likelihood of successful CPR.…”

“…38,[63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78] Of these 17 articles, 12 were deemed low-quality studies, [63][64][65][66][67][68][72][73][74][75][76][77] two were deemed medium quality 38,71 and three were deemed high quality. 69,70,78 Twelve articles included reviews or audits of medical records, registry of deaths or MET calls, 16,75,[79][80][81][82][83][84][85][86][87][88] of which two were of high quality 16,86 two were of medium quality 85,…”