Patient preferences for “Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)” decisions and how health services deal with them are the subject of a review published by the UK National Institute for Health Research.
Prof. Gavin Perkins, professor of critical care medicine, University of Warwick, and colleagues, set out to identify why conflict and complaints arise, examine inconsistencies in NHS trusts’ implementation of national guidelines and to 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.
The literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making, whilc linking DNACPR to treatment plans improved communication, reduced harms and helped to make goals of care clearer. Use of standardised documentation meant that decisions were recorded more often and with better quality.
The NIHR’s stakeholder meetings revealed concerns from the public that their wishes about resuscitation would not be respected. Some health professionals are put off bringing up CPR decisions in case of complaints or conflict. All the groups and the literature review brought up the theme of the negative impact on patient care of having a DNACPR decision, as ‘do not resuscitate’ can be confused with ‘do not provide active treatment’.
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The report’s authors found evidence that the whole area of DNACPR decisions - consideration, discussions, communication, implementation and consequences - varied greatly. However, the report’s authors note that the strongest ethical message their data reveals is that decisions about cardiopulmonary resuscitation are complex and context specific, and should be seen as one aspect of the holistic care of an individual patient.
The report authors recommend further research on:
- training strategies that will equip clinicians to make DNACPR decisions, including an understanding of the nature and the complexity of the decisions together with the associated communication skills
- the utility of clinical prediction tools to reduce uncertainty and variation in decision-making
- evaluating a national system for DNACPR decisions within overall care and treatment plans should there be such an initiative.
The stakeholder group’s recommendations for research were:
- research to identify the impact of DNACPR decisions on other aspects of care
- evaluation of different strategies to improve public education about DNACPR.