Predictors of do not resuscitate orders in the nursing home

Messinger‐Rapport, Barbara J.; Kamel, Hosam K.

doi:10.1016/j.jamda.2004.12.006

Cited by 41 publications

(45 citation statements)

References 17 publications

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“…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,…”

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%

“…Despite this, many other studies indicated that older age was still a key consideration. 16,64,72,79,80,83,85,86,88 The age of the older patient was differently defined but started as young as 67 years. 16 One study 66 explained this more broadly, in that the proportion of patients undergoing CPR decreased with increasing age and was significantly lower for patients over 80 years of age; in one example, 78,93 it was found that younger patients were more likely to have CPR and longer attempts at CPR, whereas older patients in similar circumstances would have a DNACPR order in place.…”

Section: Epidemiologymentioning

confidence: 99%

“…72,75,79,80,83,93 The frequency of intensive care unit (ICU) stays 83 and previous resuscitations 64,72 were also important contributors to DNACPR decision-making.…”

Section: Prognosismentioning

confidence: 99%

“…80,85 Being unmarried, 84 having pastoral care, 85 a lack of bystander basic life support at cardiac arrest and ineffectiveness of basic life support 66 were also mentioned.…”

Section: 93mentioning

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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Section: Considering the Decisionmentioning

confidence: 99%

Section: Considering the Decisionmentioning

confidence: 99%

Section: Epidemiologymentioning

confidence: 99%

“…72,75,79,80,83,93 The frequency of intensive care unit (ICU) stays 83 and previous resuscitations 64,72 were also important contributors to DNACPR decision-making.…”

Section: Prognosismentioning

confidence: 99%

“…80,85 Being unmarried, 84 having pastoral care, 85 a lack of bystander basic life support at cardiac arrest and ineffectiveness of basic life support 66 were also mentioned.…”

Section: 93mentioning

confidence: 99%

See 3 more Smart Citations

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

Perkins

Griffiths

George

et al. 2016

Health Serv Deliv Res

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Characteristics of patients who refuse do‐not‐resuscitate orders upon admission to an acute palliative care unit in a comprehensive cancer center

Parsons

Cruz

Zhukovsky

et al. 2010

Cancer

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BACKGROUND: Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit. METHODS: A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis. RESULTS: Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P ¼ .0005), nausea of 2 (0-7) versus 1 (0-4, P ¼ .05), and dyspnea of 1 (0-5) versus 4 (0-7, P ¼ .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P ¼ .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P ¼ .002) and with no advance directives (OR, 2.94; P .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P .0001). CONCLUSIONS: DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions. Cancer 2010;116:3061-70.

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Patient–physician communication about code status preferences

Rhondali

Perez‐Cruz

Hui

et al. 2013

Cancer

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Purpose Code status discussions are important in cancer care. The best modality for such discussions has not been established. Our objective was to determine the impact of a physician ending a code status discussion with a question (autonomy approach) versus a recommendation (beneficence approach) on patients' do-not-resuscitate (DNR) preference. Methods Patients in a supportive care clinic watched two videos showing a physician-patient discussion regarding code status. Both videos were identical except for the ending: one ended with the physician asking for the patient's code status preference and the other with the physician recommending DNR. Patients were randomly assigned to watch the videos in different sequences. The main outcome was the proportion of patients choosing DNR for the video patient. Results 78 patients completed the study. 74% chose DNR after the question video, 73% after the recommendation video. Median physician compassion score was very high and not different for both videos. 30/30 patients who had chosen DNR for themselves and 30/48 patients who had not chosen DNR for themselves chose DNR for the video patient (100% v/s 62%). Age (OR=1.1/year) and white ethnicity (OR=9.43) predicted DNR choice for the video patient. Conclusion Ending DNR discussions with a question or a recommendation did not impact DNR choice or perception of physician compassion. Therefore, both approaches are clinically appropriate. All patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for the video patient. Age and race predicted DNR choice.

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Predictors of do not resuscitate orders in the nursing home

Cited by 41 publications

References 17 publications

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

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

Characteristics of patients who refuse do‐not‐resuscitate orders upon admission to an acute palliative care unit in a comprehensive cancer center

Patient–physician communication about code status preferences

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