Documentation of resuscitation decision-making: A survey of practice in the United Kingdom
Introduction
The first documentation of cardiopulmonary resuscitation (CPR) decisions began in the 1960's following the widespread introduction of the CPR technique.1 It was presumed that the treatment would be for all patients and notification was required if CPR was not to be instituted.2 The first Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders were generally vague and institution specific, with text entries such as “not for 222's” written into the notes.3, 4 The majority of the time no formal documentation was in place and orders were communicated verbally between medical and nursing staff.
Papers from the 1980s debated the appropriateness of DNACPR orders.5, 6, 7 Arguments for verbal orders identified the need to keep DNACPR orders under constant review to reflect the ever-changing patient status. However, most medical professionals agreed that documentation was required to improve communication of the decision.
In England, hospitals have each created forms tailored to their needs. In contrast, in May 2010 NHS Scotland published Europe's first fully integrated national policy for DNACPR decision-making and communication in adults; the Adult DNACPR policy is supported by the Scottish Care Homes regulatory body, Scottish Police Forces and the Crown Office and Procurator Fiscal Service.
The Joint Statement by the British Medical Association, Resuscitation Council UK and Royal College of Nursing “Decisions Relating to Cardiopulmonary Resuscitation” was published in 2007.8 The statement called for greater transparency regarding DNACPR status as well as improved documentation of decisions. This statement included a sample DNACPR document that hospitals could modify and adopt. The document was well received and incorporated into many NHS trust policies. However many hospitals had already invested time in developing their own forms and policies and were content to continue with their own documents. In 2012, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) produced a report calling for a change in approach to DNACPR orders, requesting a documented resuscitation status for all acute admissions, detailed documentation regarding treatment plans and quicker escalation to senior providers if the patient's condition deteriorates.9 The NCEPOD report criticised the current state of practice, stating: “this may be the most important report the NCEPOD has produced in the last 10 years”. It emphasised the need to rethink NHS strategy towards recording resuscitation status.9
The aim of this paper is to provide a survey of current practice concerning the documentation of resuscitation decisions in the UK and to provide NHS Trusts with knowledge about how different hospitals are adapting to deal with the challenging dynamic of resuscitation documentation.
Section snippets
Methods
We contacted all NHS Acute Trusts within the United Kingdom through publicly available email addresses. The list of NHS Acute Trusts and their corresponding hospitals in England were compiled from the NHS Choices website. Northern Ireland's Health and Social Care Trusts provided the list of hospitals in Northern Ireland. In Wales, Local Health Boards have replaced NHS Acute Trusts and those health boards and their corresponding hospitals were included in the survey. If multiple hospitals were
Response rate
Our response rate was 73.3% of English Acute Trusts (118/161 trusts; 377 hospitals), 42.8% of Welsh Acute Trusts (3/7 Health Boards; 73 hospitals), 50% of Northern Ireland Acute Trusts (3/6 Acute Trusts; 25 hospitals). Scotland has only one DNACPR form in use, and so a 100% response rate. This survey accounts for a total of 731 Hospitals. All responding trusts had active policies and have a DNACPR form in use. For the remainder of the statistics, Scotland hospitals have been excluded from
Scotland
As explained above, Scotland has a region-wide form, used throughout NHS acute and community settings. The form provides specific instructions to ambulance crews, GPs and District Nurses. Respondents reported overall satisfaction with the form. The policies have now been implemented across all Scottish Health Boards, NHS 24, and the Scottish Ambulance Service.
The North East
The ‘Deciding Right’ and Yorkshire & the Humber forms are in use at approximately 45 hospitals each.10, 11 The ‘Deciding Right’ and Yorkshire & Humber regional forms are similar in format and content. Both forms rely on a tick-box structure to cover capacity and communication with patient and family.
The ‘Deciding Right’ policy applies to the North East region. It integrates “do not resuscitate” decisions with national legislation (Mental Capacity Act) and guidelines regarding capacity. Its aim
The South and the South East
In the south, England has three prominent regional forms. The free text format of the South East of England form was disseminated in 2011 and has had patchy uptake across the region. The South of England form is used along the central corridor of England and prefers the tick-box structure but also includes a “message in a bottle” option for patients.12
The South West
The Devon based Treatment Escalation Plan (TEP) deviates the most from the standard RCUK format.13, 14 The TEP allows the clinical team to communicate the appropriate level of treatment for the patient. The treatment level is detail specific, specifying antibiotics, fluids, artificial feeding, dialysis, NIV and escalation to critical care.
Besides those mentioned above, other hospitals have created forms which allow for a DNACPR decision to be valid within the community. These often contain
Discussion
In this national survey of current DNACPR practice, we found that the UK is in a period of transition. While many hospitals are looking to national guidance to help plan their policies, other hospitals are experimenting with new concepts such as regional forms, how to extend the validity of documents into the community and using “ceiling of care” plans. There is thus a tension between the value and convenience of uniformity with the desire to respond to perceived problems with the current
Conclusion
Resuscitation decisions are important and emotive. The existence of a form solely designed to indicate an individual as “not for resuscitation” with validity only within a single hospital is dwindling. Documentation is rapidly evolving to meet the needs of patients and to respond to new evidence, such as that in the NCEPOD report.
Conflicts of interest statement
Dr Zoe Fritz and Dr Jonathan Fuld are the creators of the Universal Form of Treatment Options (UFTO).
Acknowledgments
We would like to thank Juliet Spiller for her contribution on the development of the Scottish form, Alexandra Malyon for contributions to the protocol, and the resuscitation officers and others who kindly replied to our requests. This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0808-17218). The views expressed are those of the authors and not necessarily
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