Perkins, Gavin D., Griffiths, Frances, Slowther, Anne, George, R., Fritz, Zoë , Satherley, P., Williams, B., Waugh, Norman, Cooke, Matthew, Chambers, Sue, Mockford, Carole, Freeman, Karoline, Grove, Amy L., Field, R., Owen, S., Clarke, B., Court, Rachel A. and Hawkes, Claire (2016) Do-not-attempt-cardiopulmonary-resuscitation decisions : an evidence synthesis. Health Services and Delivery Research, 4 (11). doi:10.3310/hsdr04110 ISSN 2050-4349.

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Abstract

Background: Cardiac 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 objectives: This 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.

Methods: A 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.

Results: The 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’.

Limitations: The variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.

Conclusion: There 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 work: Recommendations 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 registration: This study is registered as PROSPERO CRD42012002669.

Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Item Type:	Journal Article
Subjects:	R Medicine > R Medicine (General)
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences > Population, Evidence & Technologies (PET) Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences > Social Science & Systems in Health (SSSH) Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	CPR (First aid) -- Moral and ethical aspects -- Great Britain, Great Britain. National Health Service, Medical policy
Journal or Publication Title:	Health Services and Delivery Research
Publisher:	NIHR Journals Library
ISSN:	2050-4349
Official Date:	April 2016
Dates:	Date Event April 2016 Published
Volume:	4
Number:	11
DOI:	10.3310/hsdr04110
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access (Creative Commons)
Date of first compliant deposit:	21 March 2017
Date of first compliant Open Access:	21 March 2017
Funder:	National Institute for Health Research (Great Britain). Health Services and Delivery Research (NIHR HS&DR), General Medical Council (Great Britain)
Grant number:	Grant number 12/5001/55 (NIHR HS&DR)
Related URLs:	Related item in WRAP Publisher

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