Table 2

Summary of included literature

Name and description of interventionDecisions of interestAuthor and yearCountry and healthcare settingLiterature typeStudy design and methodsStudy objective
DNACPRCeilings of active careSupportive/Palliative careCommunication guidelines around goals of care
AMBER care bundle
Care bundle consisting of a proforma and sticker
Promotes consistent communication and care planning for patients identified as facing uncertain recovery		XXCarey et al, 201436UK
Hospital
(five acute wards)		Published peer-reviewed studyDescriptive/Quantitative:
Overview of development and implementation of AMBER, and data on clinical impact		To describe the design, development and implementation of the AMBER care bundle and its impact on clinical service
Etkind et al, 201460UK
Hospital
(five acute wards)		Published peer-reviewed studyQuantitative:
Retrospective electronic case note review of patients who died in wards where AMBER was implemented		To evaluate application of the AMBER care bundle in a UK hospital and describe factors affecting its use
Morris et al, 201148UK
Hospital		Published conference abstractDescriptive:
Overview of AMBER and its implementation		Learning points from implementation of the AMBER care bundle
Doncaster and Bassetlaw Hospitals NHS Foundation Trust, 201550UK
NHS Trust		Grey literaturePolicy documentManagement of patients who are at end of life
Guy’s and St Thomas’ NHS Foundation Trust, 201255UK
NHS Trust		Grey literaturePatient guidanceThe AMBER care bundle, a guide for patients, their relatives and carers
Universal Form of Treatment Options (UFTO)
Form contextualising the CPR decision within overall treatment plans
Includes documentation and discussion of care and treatment decisions		XXXFritz et al, 20133UK
Hospital
(two acute wards)		Published peer-reviewed studyProspective mixed method:
Case note review of DNACPR patients, qualitative interviews and observations		To determine whether the introduction of UFTO reduces harms in patients in whom a DNACPR was made, and to understand the mechanisms for observed change
Fritz et al, 201531UK
Hospital
(two acute wards)		Published peer-reviewed studyExpert consensus:
Cross-disciplinary adapted Delphi method		To describe a cross-disciplinary approach to developing a universal form of treatment options as an alternative to DNACPR orders
www.ufto.org
Accessed: 1 July 201578		UKGrey literatureWebsiteUFTO: universal form of treatment options
www.ufto.org/background/scientific-background
Accessed 1 July 201543		UKGrey literatureWebsiteUFTO: scientific background
Goals of Patient Care Summary (GOPC)
Form to summarise goals of care
Serves as a guide for treatment decisions as the patient’s condition improves, stabilises or deteriorates		XXXBrimblecombe et al, 201453Australia
Hospital
(adult medical inpatients)		Published peer-reviewed studyQuantitative:
Cross-sectional review of medical inpatients and audit of inpatients requiring emergency medical review		To review the implementation of the GOPC: assess GOPC uptake, quantify completion and review outcomes of the GOPC assessment
Physician Orders for Life-Sustaining Treatment (POLST)
Form to ensure that patient wishes regarding life-sustaining treatments are honoured
Converts treatment preferences into medical orders		XXXHickman et al, 200954USA
Hospice
(hospices in 3 US states)		Published peer-reviewed studyDescriptive/Quantitative:
Survey of hospice staff members; case note review of deceased patients at subsample of POLST-using hospices		To evaluate use of POLST by hospice programmes, attitudes of hospice staff towards POLST, the effect of POLST on the use of life-sustaining treatments and the treatment options selected by patients
Gold Standards Framework for Care Homes (GSFCH) and an adapted Liverpool Care Pathway (LCP) for Care Homes
The implementation of two end-of-life care tools: the GSFCH supportive/palliative care register and an adapted LCP for Care Homes		XXXHockley et al, 201032UK
Nursing home
(seven nursing homes in Scotland)		Published peer-reviewed studyQuantitative/In-depth evaluation:
Overview of implementation, retrospective case note review of deceased residents and staff audit		To evaluate the effectiveness of a high facilitation implementation on professional practices and residents outcomes
UIHC (University of Iowa Hospital and Clinics) Policy Regarding Do Not Resuscitate Orders and End of Life Discussions with Hospitalised Patients
DNACPR order policy placing CPR discussions within a framework of end-of-life discussions, and within a larger goal-orientated context		XXXKaldjian and Broderick, 201151USA
Hospital
(academic medical centre)		Published peer-reviewed studyDescriptive:
Overview of the integration of goals of care into staff education and revision of hospital DNACPR policy; literature review and survey of hospitalised adults		To describe the background and rationale for DNACPR policy revision and development; to describe the policy itself and ongoing implementation efforts
A revised DNACPR form, decision making tools and updated CPR guidelinesXXXMbriwa and Limaye, 201459UK
Hospital
(elderly and acute medical inpatients)		Published conference abstractQuantitative:
Prospective case note audit		To assess improvement in CPR decision-making and ceiling of care documentation/discussions since the introduction of a revised DNACPR form, decision-making tools and guidelines
ProvidersSignout for Scope ofTreatment (PSOST)
A daily handover tool documenting resuscitation status, goals of care, desired and undesired interventions, in addition to standard handover information		XXXNewport et al, 201037USA
Palliative care
(inpatient unit)		Published peer-reviewed studyDescriptive:
Overview of tool development, implementation and utility		To describe the PSOST tool and evaluate its implementation and use in a palliative care unit
An intervention informing clinicians of the laws on Patients’ Rights and the importance of advanced care planning, alongside a new DNR (do not resuscitate) form
Adapted DNACPR form, putting emphasis on the motivation, participants involved and communication of the decision-making process		XXPiers et al, 201438Belgium
Hospital
(adult inpatients)		Published peer-reviewed studyQuantitative:
Prospective observational study of deceased inpatients preintervention and postintervention; cross-sectional study of patients admitted to non-intensive wards		To compare the quality of end-of-life care and DNACPR decisions between hospital wards and after a hospital-wide intervention to improve advanced care planning
Treatment Escalation Plan and Resuscitation Decision (TEP-CPR)
Treatment escalation plan tool, to be included in the resuscitation form		XXXStockdale et al, 201333UK
Hospital
(two acute wards)		Published peer-reviewed studyQuantitative/Descriptive: Case note audit and staff survey, followed by overview of TEP-CPR development; staff survey of out of hours treatment in patients with TEP-CPR and controlsTo develop and test a tool for escalation planning; to identify whether a TEP-CPR could reduce the number of patients receiving inappropriate treatments out of hours
Ceiling ofTreatment (COT) Form
Tool for improving decision-making and documentation of treatment escalation decisions		XXXDahill et al, 201334UK
Hospital
(elderly care wards)		Published peer-reviewed studyQuantitative/Descriptive:
Overview of COT development and implementation; preimplementation and postimplementation case note review of treatment escalation decisions and staff feedback survey		To develop, pilot and implement a tool to improve decision-making and the documentation of treatment escalation decisions
Powter et al, 201239UK
Hospital
(elderly care wards)		Grey literaturePoster
Quantitative/Descriptive:
Overview of COT development and implementation; prepilot and postpilot data on decision documentation and staff survey		To improve decision-making and documentation of CPR and ceiling of treatment decisions
Treatment Escalation Plan (TEP) (Devon)
Form outlining what treatment options would be appropriate if a patient were to become acutely unwell		XXObolensky et al, 20101UK
Hospital
(two acute trauma & orthopaedic wards)		Published peer-reviewed studyProspective quantitative and qualitative evaluation:
Patient/relative interviews to evaluate the TEP process		To evaluate patient and relative experiences of, and thoughts regarding the Devon TEP
Mercer, 200961UK
Hospital		Published letterLetter to the editor
Descriptive:
Overview of TEP process		The death of DNR: TEPs
Obolensky and Mercer, 200766UK
Hospital		Published conference abstractDescriptive/Quantitative:
overview of TEP process and staff survey		To evaluate initial impact of the Devon TEP from a clinical staff perspective
Obolensky and Mercer, 200756UK
Hospital		Published conference abstractDescriptive/Quantitative: overview of TEP process and patient surveyTo evaluate patient experiences of the Devon TEP
Karakusevic44UK
Hospital
(acute hospital)		Grey literaturePoster
Descriptive:
Overview of background to development and TEP implementation		To evaluate implementation of the Devon TEP
Torbay and Southern Devon Health and Care NHS Trust, 201452UK
NHS Trust		Grey literaturePolicy documentTEP and resuscitation decision records policy
Care Quality Commission (CQC), 201446UK
NHS Trust		Grey literatureCQC reportNorthern Devon Healthcare NHS Trust, end-of-life care quality report
Rowcroft Hospice, 201357UK
Hospice		Grey literaturePatient guidanceTEP forms, public information document
Devon Local Medical Committee, 201379UKGrey literatureStaff guidanceTEP—newsletter update article
Macmillan Cancer Support, St Luke’s Hospice Plymouth & North, East and West Devon Clinical Commissioning Group80UK
Hospice		Grey literatureStaff guidanceNew TEP form (V.10)—frequently asked questions document
North Devon Healthcare NHS Trust81UK
NHS Trust		Grey literatureStaff guidanceStaff briefing note on the use of TEPs
NHS Improving Quality Team, 201482UKGrey literatureStaff guidanceGuidance for completing TEP and resuscitation decisions
Treatment Escalation Plan (TEP)
Tool for planning the care of a patient at risk of deterioration		XXXPaes and O’Neill, 201262UK
Hospital
(six acute specialties)		Published conference abstractDescriptive/Quantitative:
Pilot, audit and staff feedback survey		To evaluate staff feedback and decision-making outcomes before and after TEP introduction
Paes, 201263UK
Hospital
(six acute wards and community hospital)		Grey literaturePoster
Descriptive/Quantitative:
Overview of TEP implementation and next steps; case note review audit before and after TEP pilot, and staff survey		To pilot TEP and evaluate staff feedback, out of hours decision-making/discussions and TEP completion outcomes; to determine whether and how TEP should be introduced across the trust
HDU (high dependency unit) Specific Treatment Escalation Plan
Plan for ceiling of treatment and escalation level decision on every patient within 24 hours		XXHannah, 201440UK
Hospital
(medical HDU)		Grey literaturePoster
Descriptive:
Overview of TEP development, implementation and next steps, including informal staff feedback		To describe and evaluate the process of TEP development and its implementation in a medical high dependency unit
Treatment Escalation Plan (TEP) ProformaXXXThomson et al, 201464UK
Hospital
(acute medicine)		Grey literaturePoster
Quantitative:
Case note review audit before and after TEP pilot, and staff survey		To pilot TEP and evaluate staff feedback and DNACPR/TEP documentation outcomes
Cornwall Treatment Escalation Plan and Resuscitation Decision RecordXXRoyal Cornwall Hospitals NHS Trust, 201549UK
NHS Trust		Grey literaturePolicy documentTEP and resuscitation decision record policy
Escalation plan and resuscitation status (EPARS)
Form amalgamating escalation plan and CPR decisions		XXXWest Suffolk NHS Foundation Trust, 201345UK
NHS Trust		Grey literaturePolicy documentTrust policy and procedure:
EPARS (including DNACPR)
TreatmentEscalation Plan (TEP)XXBasildon and Thurrock University Hospitals NHS Foundation Trust, 201458UK
NHS Trust		Grey literaturePatient guidanceTEP patient information
Content guidelines for discussions of CPR and life-sustaining therapy
Guidelines for the content of a discussion about resuscitation or goals of care		XXXDownar and Hawryluck, 201041Canada
Hospital
(12 physicians)		Published peer-reviewed studyExpert Consensus:
Delphi method to develop content guidelines		To develop content guidelines for discussions of CPR and life-sustaining therapy
A palliative care treatment plan intervention
Best practice guidance supported by a staff education programme, electronic decision support tool and paper educational tools		XBailey et al, 201447USA
Hospital
(inpatient units at six veteran medical centres)		Published peer-reviewed studyDescriptive/Quantitative:
Overview of intervention and its multicentre implementation; preimplementation and postimplementation case note review of end of life care in deceased patients		To evaluate the effectiveness of a multimodal intervention strategy to improve the processes and quality of end-of-life care in acute inpatient settings
The Palliative Care forAdvanced Disease (PCAD) pathway
To improve palliative care for inpatients who are expected to die from advanced disease; clinical pathway including:
–interdisciplinary care pathway
–nurses documentation flowsheet
–physicians order sheet with guidelines for symptom management		XBookbinder et al, 200542USA
Hospital
(3 inpatient units)		Published peer-reviewed studyDescriptive/Quantitative:
Overview of intervention, its development and implementation; case note review of care outcomes in patients who died before and during implementation, in both intervention and control units		To describe the development and quality improvement strategy for the implementation of PCAD; to pilot and evaluate the utility of PCAD
Serious illness conversation guide
Guide describing key elements to be addressed in patient conversations about serious illness care goals		XXBernacki and Block, 201465USAPublished peer-reviewed studyLiterature review and synthesis of best practices in conversations about serious illness care goalsTo provide clinicians with practical, evidence-based advice (in the form of a serious illness conversation guide)
The VOICE (Values Options in Cancer Care) intervention
Education and coaching communication intervention
To facilitate communication and decision-making among oncologists, patients and caregivers		XHoerger et al, 201335USA
Oncology services		Published peer-reviewed studyDescriptive:
Overview of intervention and its planned implementation as part of an RCT		To describe the study design and rationale for a patient-centred communication and decision-making intervention for physicians, patients with advanced cancer and their caregivers

  • CPR, cardiopulmonary resuscitation; DNACPR, do not attempt cardiopulmonary resuscitation; TEP, treatment escalation plan; NHS, National Health Service; RCT, randomised controlled trial.