Prevalence of ‘do not attempt resuscitation’ orders and living wills among patients suffering cardiac arrest in four secondary hospitals
Introduction
Since the early 1960s cardiopulmonary resuscitation (CPR) has become standard practice in sudden cardiac arrest (CA), both in and outside hospitals. Published results on survival to hospital discharge from in-hospital CPR range from 10 to 20% [1], [2] whereas long-term survival rates are considerably lower [3]. There are situations when CPR can be considered futile (e.g. in cases of terminal disease). In such cases patients are assigned a ‘do not resuscitate’ (DNR) order that precludes the use of resuscitative measures. In recent years it has been suggested that the term DNR should be replaced with ‘do not attempt resuscitation’ (DNAR) to eliminate unfounded confidence, wishes and beliefs by the patient and relatives [4].
International studies have shown that DNAR is frequently applied for terminally ill patients [5], [6], [7]; however, in Scandinavia such studies have not been published. The DNAR order is often the first step towards a line of palliative care [8], [9]. Ethical guidelines emphasize patient autonomy [10], [11], but such decisions as DNAR orders are often not reached until the patient is already unable to communicate [8], [12]. In a recent study, most hospitals in Finland reported having a DNAR policy but few of them had written DNAR guidelines [13]. A similar situation was reported in a Dutch survey [14].
In Finland the living will is a request by the patient to stop treatment that is likely to prolong life but cannot be expected to improve his or her condition. It is based on the Finnish Law on the Patient's Status and Rights (1992), and it is usually expressed in written form. The Ministry of Social Affairs and Health, as well as some other organizations, has published a form for a living will, but patients can also write their own without any official form. The problem with the living will is that, according to many studies, it has had minimal effect on patient care [15], [16].
An essential part of efficient in-hospital resuscitation management is uniform practice also concerning the implementation of DNAR orders. This need is also recognized in the Utstein style for in-hospital CA, published in 1997 [17]. The template includes information on reasons for not initiating CPR, which are, nevertheless, seldom reported [2], [18].
The purpose of this study was to assess the prevalence and implications of DNAR orders and living wills for patients suffering in-hospital CA without CPR being initiated in four secondary hospitals in Finland during 1 year. The data were collected according to the Utstein style. An analysis of data on resuscitated patients collected simultaneously in the same hospitals has been published separately [19].
Section snippets
Setting
This study was performed in 2000–2001. Four of the 16 central hospitals in Finland namely, the Etelä-Karjala Central Hospital (EK-CH), the Jyväskylä Central Hospital (J-CH), the Päijät-Häme Central Hospital (PH-CH) and the Vaasa Central Hospital, participated in the study. The characteristics of the hospitals are given in Table 1.
DNAR policy
All the hospitals reported that they had a DNAR policy, but none of them had written guidelines. Accordingly none of the hospitals had a policy for documentation. In
Demographic data
During the study period, 1486 patients suffered CA without CPR being initiated. In 1143 (77%) of these cases the registration form was filled out and included in the study. The mean-age of the patients was 71 (range 1–98, standard deviation (S.D.) 14.5) years; 648 (57%) were male.
During the study period 204 patients (12%) were resuscitated. Their mean-age was 68 (range 0–96, S.D. 15.8) years; 121 (59.3%) were male.
DNAR orders
At time of death, 966 (84.5%) of those who died without CPR, had a DNAR order.
Prevalence of DNAR orders
The purpose of a DNAR order is to avoid resuscitative measures when the chance of meaningful long-term survival is considered to be very low. This study shows that the majority of patients (84.5%) who died without initiated resuscitation had a DNAR order. A similar prevalence (82%) has been reported from the Sahlgrenska hospital in Göteborg, Sweden [20] and an even a higher prevalence (90%) was found at the Liverpool hospital in Sydney, Australia (Parr, personal communication). A somewhat lower
Conclusion
In our study most of the patients who suffered CA in four secondary Finnish hospitals without resuscitative measures had a DNAR order present. For those who did not, a terminal disease was often evident. However, there was inconsistency in initiating resuscitation among patients not having a DNAR and suffering CA on the wards. The documentation policy could probably be corrected with uniform national DNAR guidelines. Living wills were uncommon in our series. Patients with a living will were
Acknowledgements
This study was supported by generous grants from Finska Läkarsällskapet, The Laerdal Foundation for Acute Medicine and Tor och Kirsti Johanssons Hjärt – och Cancerstiftelse, and they are gratefully acknowledged.
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Cited by (24)
European Resuscitation Council Guidelines 2021: Adult advanced life support
2021, ResuscitationCitation Excerpt :Identifying and treating physiological deterioration early to prevent cardiac arrest. Most patients who die in hospital do not have a resuscitation attempt.7–10 The ERC Ethics guidelines promote shared decision making and advanced care planning which integrates resuscitation decisions with emergency care treatment plans to increase clarity of treatment goals and also prevent inadvertent deprivation of other indicated treatments, besides CPR.
Prearrest prediction of favourable neurological survival following in-hospital cardiac arrest: The Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score
2019, ResuscitationCitation Excerpt :This however, would not have given us the opportunity to adapt the model to temporal changes and local conditions, nor add chronic comorbidity as a predictor. Chronic comorbidity has emerged as an independent predictor of outcome for IHCA,22–25 and according to our clinical experience, with support from a few published studies, chronic comorbidity is part of the predictive assessment for decisions regarding DNAR orders.6,36 The AUROC for the GO-FAR score in this cohort was slightly higher than for the PIHCA score (0.8214 vs 0.808).
Level of agreement on resuscitation decisions among hospital specialists and barriers to documenting do not attempt resuscitation (DNAR) orders in ward patients
2011, ResuscitationCitation Excerpt :Barriers to timely documentation of DNAR orders should be addressed, including anticipating deterioration in patients with multiple co-morbidities that require acute hospital admission, raising awareness of expected mortality, timely end-of-life discussions with patients and families, collaborative discussions with other specialist clinicians involved in patient care, and maintaining continuity of clinical care and handover. Previously DNAR practices have been shown to vary between medical specialities14; however in our study there were no trends towards differences of opinion between specialities. It may be the disagreement on DNAR orders were due to the primary clinician's better knowledge of the patients’ medical state.
Part 12: Education, implementation, and teams: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
2010, ResuscitationCitation Excerpt :In adult patients with cardiac arrest, 18 additional studies (LOE 1594–597; LOE 2598–600; LOE 4601–606; LOE 5607–611) did not support the use of advance directives (e.g., living wills), compared with no such directives, to improve outcome defined as resuscitative efforts based on patient preference. Evidence from one LOE 3 study612 suggested that the presence of a DNAR order decreased CPR rates. No study was found that specifically addressed these issues in children.
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