Elsevier

Resuscitation

Volume 58, Issue 1, July 2003, Pages 65-71
Resuscitation

Prevalence of ‘do not attempt resuscitation’ orders and living wills among patients suffering cardiac arrest in four secondary hospitals

https://doi.org/10.1016/S0300-9572(03)00109-6Get rights and content

Abstract

Objective: To assess the prevalence and implementation of ‘do not resuscitate’ orders, nowadays called ‘do not attempt resuscitation’ (DNAR) orders and living wills among patients suffering in-hospital cardiac arrest (CA) in whom cardiopulmonary resuscitation was not initiated. Materials and methods: A prospective survey of CA patients conducted in four secondary hospitals during 2000–2001. The information collected included the presence of DNAR and a living will and the patients sociodemographic and disease factors and the reasons for not initiating resuscitation when no DNAR order was present. Data on the resuscitated patients were collected according to the Utstein recommendations (analyzed and published separately) and used for comparison. Results: During the study period, 1486 patients suffered CA without resuscitation being initiated. Data collection was successful in 1143 patients (77%), who were included in the study. Most of the patients (84.5%) had a DNAR order. The prevalence of DNAR orders differed between the participating hospitals (P<0.001), and between the wards of the hospital, with most DNAR orders in the cardiac care unit (100%) and medical wards (87%). The patients designated as DNAR were likely to be older (P<0.01) and of poorer functional status (P<0.001). Reasons for abstaining from resuscitation without a DNAR order were unwitnessed arrest (27%) and terminal disease (66%). Living wills were uncommon (1.5%). Patients with a living will were likely to have a DNAR order (P<0.01). Conclusion: Most patients who suffered in-hospital CA without resuscitation had a DNAR order, and, for those who did not, terminal disease and medical futility were evident in most cases. Living wills were uncommon, but they appeared to have had some impact on treatment.

Sumàrio

Objectivo: Avaliar a prevalência e implementação das ordens “Não tentar Reanimar”, hoje em dia designadas “Do not attempt resuscitation” (DNAR) (Não tentar reanimar) e Testamentos de Vida entre as vı&#x0301;timas de Paragem Cardı&#x0301;aca (CA) intra-hospitalar nos quais não foram iniciadas manobras de reanimação cardio-pulmonar. Material e método: Fez-se um questionário prospectivo às vı&#x0301;timas de CA, em quatro hospitais secundários durante 2000-2001. A informação recolhida incluı&#x0301;a a presença de DNAR, o Testamentos de Vida, factores socio demográficos, doença da vı&#x0301;tima e as razões porque não foram iniciadas manobras de reanimação quando não existia nenhuma ordem DNAR. Os dados das vı&#x0301;timas reanimadas foram recolhidos de acordo com as recomendações Utstein (analisados e publicados separadamente) e utilizados para comparação. Resultados: Durante o perı&#x0301;odo de estudo, verificou-se existirem 1486 vı&#x0301;timas de CA em que não foram iniciadas manobras de reanimação. Foi possı&#x0301;vel realizar uma colheita de dados com sucesso em 1143 doentes (77%), estes foram os incluı&#x0301;dos no estudo. A maioria dos doentes (84.5%) tinha uma ordem DNAR. A prevalência das ordens de DNAR diferiu entre os hospitais que participaram (P<0.001), e entre as enfermarias do hospital, com a maioria das ordens DNAR na Unidade de Cuidados Cardı&#x0301;acos (100%) e nas enfermarias médicas (87%). Os doentes designados como DNAR tinham uma maior probabilidade de serem mais velhos (P<0.01) e de terem um estado funcional mais pobre (P<0.001). As razões referidas para não terem sido realizadas manobras de Reanimação apesar de não existirem ordens DNAR foram: a paragem testemunhada (27%) e doença terminal (66%). Foram pouco comuns as expressões de “Testamentos de Vida” (1.5%). É mais provável que os doentes com uma vontade expressa relativamente ao desejo de viver tenham uma ordem DNAR (P<0.01). Conclusão: A maioria das vı&#x0301;timas de Paragem cardı&#x0301;aca (CA) intra-hospitalar tinha uma ordem de DNAR; a doença terminal ou a futilidade médica eram evidentes para a maioria daqueles casos em que não existia ordem de DNAR. É pouco frequente a expressão do desejo relativamente à vida, mas esta parece ter algum impacto no tratamento.

Resumen

Objetivo: Evaluar la prevalencia e implementación de órdenes de ‘no reanimar’, hoy llamadas órdenes de ‘no intentar reanimar’ (DNAR), entre pacientes que sufren paro cardı&#x0301;aco (CA) intra hospitalario en quienes no se inició reanimación cardiopulmonar. Material y métodos: Encuesta prospectiva de pacientes con CA, conducida en 4 hospitales secundarios durante 2000–2001. La información recolectada incluı&#x0301;a la presencia de órdenes de DNAR o deseo en vida y los factores de enfermedad y sociodemográficos del paciente, y las razones para no iniciar reanimación cuando existı&#x0301;a una orden de DNAR. Los datos de los pacientes resucitados fue recolectada de acuerdo a las recomendaciones de Utstein (analizadas y publicadas en forma separada) y utilizados para comparación. Resultados: Durante el perı&#x0301;odo de estudio, 1846 pacientes sufrieron paro cardı&#x0301;aco sin que se iniciara reanimación. La recolección de datos fue exitosa en 1143 pacientes (77%), que fueron incluidos en este estudio. La mayorı&#x0301;a de3 los pacientes (84.5%) tenı&#x0301;an orden DNAR. La prevalencia de órdenes DNAR diferı&#x0301;a entre los hospitales participantes (P<0.001), y entre las distintas salas de un hospital, con el máximo de órdenes de DNAR en unidades de cuidados cardı&#x0301;acos (100%) y salas de medicina (87%). Los pacientes designados como DNAR eran probablemente más viejos (P < 0.01) y de estado funcional más pobre (P<0.001). La razones para abstenerse de reanimar aquellos sin DNAR fueron el paro no presenciado (27%) y enfermedad terminal (66%). Deseo manifestado en vida fue poco común (1.5%). Los pacientes con deseo manifestado en vida tenı&#x0301;an alta probabilidad de tener DNAR (P<0.01). Conclusión: La mayorı&#x0301;a de los pacientes que sufrieron un CA intrahospitalario sin reanimación tenı&#x0301;an una orden de DNAR, y para la mayorı&#x0301;a de aquellos que no la tenı&#x0301;an, era evidente la presencia de enfermedad terminal o futilidad médica en la mayorı&#x0301;a de los casos. Deseos manifestados en vida fueron infrecuentes, pero parecieron tener algún impacto en el tratamiento.

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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