Including patients in resuscitation decisions in Switzerland: from doing more to doing better

Hurst, Samia; Becerra, Maria Isabella; Perrier, Arnaud; Perron, Noëlle Astrid Junod; Cochet, Stéphane; Elger, Bernice Simone

doi:10.1136/medethics-2012-100699

Cited by 37 publications

(56 citation statements)

References 42 publications

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“…DNAR-Entscheidungen und zu DNAR gehörige Besprechungen sollen klar in der Akte des Patienten aufgezeichnet werden [1001][1002][1003][1004]. Mit der Zeit kön-nen sich die Situation oder die Ansichten des Patienten ändern, sodass DNAR-Anweisungen entsprechend überprüft werden sollen [1005].…”

Section: Anwesenheit Der Familie Während Der Reanimationunclassified

Kurzdarstellung

Monsieurs

Nolan

Bossaert

et al. 2015

Notfall Rettungsmed

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Section: Anwesenheit Der Familie Während Der Reanimationunclassified

Kurzdarstellung

Monsieurs

Nolan

Bossaert

et al. 2015

Notfall Rettungsmed

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“…Apart from these diseases and background factors, patients with sequelae of cerebrovascular disease or dementia or patients in a persistent vegetative state may lack decision‐making capability. Although a lack of decision‐making capability or the presence of a communicative disorder are typically identified as reasons why patients do not (or cannot) participate in the decision‐making process for DNAR orders,14 the existence of background factors such as cerebrovascular disease, dementia, or persistent vegetative state is likely to influence the lack of patient involvement in this process. However, the proportion of cerebrovascular disease, dementia, and persistent vegetative state in patients described in this questionnaire was extremely small compared to the rate of patients who were not involved in decision‐making on DNAR orders, suggesting that lack of decision‐making capability is not the only reason for the lack of patient involvement.…”

Section: Discussionmentioning

confidence: 99%

Do not attempt resuscitation order in Japan

Inokuchi

Kobayashi

Ohkubo

2017

Acute Medicine & Surgery

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AimIn Japan, the do not attempt resuscitation (DNAR) order is practised routinely even though no related laws or guidelines exist. This study aimed to clarify the current status of DNAR, reveal existing DNAR‐related issues, and improve the application of DNAR.MethodsA questionnaire survey of medical institutions in Kanagawa Prefecture (total population, 9,120,000) about the current status of DNAR was carried out.ResultsThe results showed that DNAR has been practised at approximately 90% of the hospitals surveyed, but only about 30% have developed in‐hospital DNAR guidelines. Approximately 80% of the hospitals do not involve patients in the decision on their own DNAR orders. Because the DNAR order has not been legislated, it is often unclear whether to resuscitate patients when a request for an ambulance is made for a cardiac arrest at home.ConclusionIt is necessary for prefectures, municipalities, and local medical control authorities to take the initiative in establishing an ordinance on DNAR orders and developing guidelines.

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“…69,70 Patient and family wishes for resuscitation were sometimes reported as key to decision-making. 83,93 Although patient autonomy played an important role, 72,75,89 particularly among nurses, 73 one study 64 found that it did not significantly change the physician's decision. However, the presence of family, particularly adult children as surrogate decision-makers, 72,84,85 often aided decision-making.…”

Section: Key Decision-makersmentioning

confidence: 99%

“…Thirty-seven articles contributed to this theme and 17 included a questionnaire or survey design. 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 …”

Section: Considering the Decisionmentioning

confidence: 99%

“…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 85,87 and eight were of low quality. 75,[79][80][81][82][83][84]88 Eight articles included qualitative designs of interviews, focus groups and observations; 14,15,40,67,[89][90][91][92] of these, three were deemed high quality, 15,89,92 three were deemed medium quality 14,40,91 and two were deemed low quality. 67,90 Records after duplicates removed (n = 3098)…”

Section: Considering the Decisionmentioning

confidence: 99%

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

Perkins

Griffiths

George

et al. 2016

Health Serv Deliv Res

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BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Including patients in resuscitation decisions in Switzerland: from doing more to doing better

Cited by 37 publications

References 42 publications

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Do not attempt resuscitation order in Japan

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

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