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Characteristics of patients receiving do-not-attempt-resuscitation orders in a Brazilian tertiary hospital
Abstracts / Resuscitation 81S (2010) S1–S114
S113
Ethics
AP315
AP313
Characteristics of patients receiving do-not-attempt-resuscitation orders in a Brazilian tertiary hospital
Resuscitation in general medical wards: Who decides? DeKeyser Ganz
F. 1 ,
Israel
S. 1 ,
Hersch
M. 2 ,
Varon
J. 3 ,
Einav
Timermanthiago L.T., Timerman S., Quilici A.P., Gonzalez M.M., Ramires J.A. S. 2
1 MSc
Program, Hadassah Medical Centre School of Nursing, Jerusalem Israel 2 Intensive Care Unit, Shaare Zedek Hebrew University Medical Center, Jerusalem, Israel 3 University of Texas Health Science Center, Houston, Texas, USA Purpose: To investigate nurse experiences/attitudes regarding resuscitation with emphasis on intentional delay/avoidance of action. Methods: An anonymous questionnaire survey conducted among 122/142 nurses from five Medical wards in two Jerusalem hospitals. Results: Respondents were predominantly non-religious (n = 87, 74%) women (n = 93, 79%) under the age of 45 (n = 109, 87%) who had been CPR-certified within <2 years (n = 69, 63%). Most participated in >6 cardiopulmonary resuscitations in the past year (n = 72, 61%) and 95% had been the first on scene at least once (n = 113). Most respondents had participated in, or initiated, resuscitations they considered futile a-priori (n = 106, 89%; n = 104, 87%, respectively). Only half had been consulted by doctors regarding resuscitation in the past. Most felt they should be party to resuscitation decisions (n = 99, 84%). Several respondents had intentionally delayed (n = 22, 19%) or altogether avoided (n = 19, 16%) resuscitative actions. Some felt they are not professionally obligated to always initiate resuscitation (44%, n = 51) and some felt they may decide whether to initiate resuscitation or not despite written do not attempt resuscitation orders (32%, n = 37). Almost a third of the respondents considered intentional delay/non-initiation of resuscitation by the nurse permissible. Conclusions: Nurses act against their personal judgment in performing resuscitations they consider futile. They are often excluded from the resuscitation decision-making process despite their interest to participate. Delayed initiation/avoidance of resuscitation is considered allowable practice and is being actively practiced by some of these nurses. Nurses should be given the opportunity to voice their opinions regarding resuscitation lest they independently pre-empt medical resuscitation decisions. doi:10.1016/j.resuscitation.2010.09.458 AP314 Validation of the termination guideline for out of hospital arrest of Korea Eun J.G. 1 , Kwon M.K. 2 , Park Sh. 2 , Shin J.S. 2 , Kim M.J. 3 , Chung S.P. 3 , Lee H.S. 3 , Na J.U. 1 , Lee Y.H. 1 , Chang H.W. 1 , Shin T.G. 1 , Sim M.S. 1 , Jo I.J. 1 , Song H.G. 1 , Song K.J. 1 1 Department
of emergency medicine, Samsung Medical Center, Seoul, Korea Department of emergency medicine, Seoul Medical Center, Seoul, Korea 3 Department of emergency medicine, Gangnam Severance Hospital, Seoul, Korea 2
Purpose: Out-of-hospital cardiac arrest (OHCA) has low probability of survival to hospital discharge. According to multicenter study in Korea, survival to hospital discharge rate is 4.1%. Some of termination guidelines have been developed for use when resuscitation has no potential benefit for a victim. The BLS and ALS termination-of-resuscitation (TOR) rules revealed that it performed well in identifying patients with little or no chance of survival. There is no study about termination of resuscitation in Korea. So, we applied current using TOR rules to our OHCA patient data retrospectively, to validate appropriacy of BLS and ALS TOR rules in Korea. Materials and methods: We collected out of hospital arrest data from 3 hospitals in KOREA prehospital cardiac arrest registry between January 1, 2009, and December 31, 2009. And, for validation of the termination guideline, we applied BLS and ALS TOR rules derived from the OPALS (Ontario Prehospital Advanced Life Support) group’s large registry of cardiac arrest to these data retrospectively. We measure specificity and positive predictive value of each BLS and ALS TOR rule. Results: Total 131 cases were enrolled. The overall rate of survival to hospital discharge was 14.5% (n = 19). Of 102 patients who met BLS criteria TOR rules, 8 patients (7.8%) survived to hospital discharge. Of 52 patients who met ALS criteria TOR rules, 4 patients (7.7%) survived to hospital discharge. The BLS rule had a specificity of 0.57 (95% CI 0.33–0.79) and a positive predictive value of 0.92 (95% CI 0.85–0.97). The ALS rule had a specificity of 0.78 (95% CI 0.54–0.93) and positive predictive value of 0.92 (95% CI 0.81–0.97). Conclusions: In this study, the BLS and ALS TOR rules had relative low positive predictive value and did not performed in identifying patients with little chance of survival in KOREA. Further research about termination-of-resuscitation is needed regarding environment in Korea.
Laboratory of Emergency Cardiology Simulation, Heart Institute-InCor, Brazil Background: Do-not-attempt-resuscitation (DNAR) orders are common in hospitalized patients, however, both the epidemiological characteristics of this population and the association between the DNR orders and the level of measurable sickness are not well established. Methods: Charts from 337 consecutive patients who received a DNAR order were reviewed (July 2004 to September 2005). Variables studied included age, gender, comorbidities, major and secondary diagnosis, previous cardiac arrest (CA), Ejection fraction, site of CA, use of vasoactive drugs and orotracheal intubation, which were collected after the arrest. Results: The three most common comorbidities present before hospitalization were hypertension (46.6%), diabetes (27.6%) and chronic renal failure (23.4%), followed by previous stroke (13.9%), coronary artery disease (12.8%), dyslipidemia (11.6%) and Chagas cardiomiopathy (7.1%). No previous CA was found in 81.3% of the subjects who received the DNAR order, while 1, 2, 3 and 4 arrests were found in 13.4%, 3.3%, 1.8% and 0.3%, respectively. Most patients were admitted into the hospital with a diagnosis of Cardiovascular Disease (67.1%), Pulmonary Disease (14.9%) and Stroke (5.4%). Final diagnosis of infectious disease was present in 63.9%. Ejection fraction was normal in 1.2% of individuals, while mild (14.5%), moderate (37.1%) and severe (47.2%) dysfunction were observed in the remaining. During the stay, 13.6% presented Respiratory Distress, 69.1% with Acute Renal Failure, 88% with Shock of any cause, 90.9% needed support with vasoactive drugs and 94.3% were already intubated at the time of cardiac arrest. The average hospitalization time was 33 days. The most common site of arrest was the ICU, with 56.6% of the patients, followed by the Coronary Unit (22%) and the Emergency Room (17.5%). Conclusion: This data indicates that illness severity, present in patients receiving a DNAR order from this tertiary cardiology hospital, combined with family willingness seems to direct the decision to not attempt resuscitation. doi:10.1016/j.resuscitation.2010.09.460 AP316 ‘Do not attempt cardiopulmonary resuscitation’ orders: A transition from medical beneficence to patient autonomy Garbharran U. 1,2 , Chandarana K. 1,2 1 Elderly 2
Care Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Royal College of Physicians (London)
Purpose of the study: The British Medical Association, Resuscitation Council (UK) and Royal College of Nursing recommend that ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders should be discussed with all competent patients. However there is poor compliance with this guidance in the UK. Our aim was to assess whether this practice could be positively influenced by an intervention strategy at the Kent & Canterbury Hospital (KCH). This strategy was aimed at the multidisciplinary team to raise awareness of DNACPR guidelines thereby increasing patient participation. Materials and methods: On a randomly selected date, all DNACPR orders at the KCH were prospectively surveyed. Based on these findings, an education programme was implemented for junior doctors, consultant physicians and nurses. In addition, an integrated care pathway was developed and displayed on all wards. Consultant physicians were encouraged to consider DNACPR decisions on all patients at the point of admission using a checklist. Nine months following the above interventions, a further survey of DNACPR orders was performed. Results: The number of DNACPR orders surveyed pre- and post-intervention was 40 (19 men and 21 women, mean age 83) and 41 (26 men and 15 women, mean age 82), respectively. Eight patients lacked capacity and were excluded from further analysis. There was no significant difference between the pre- and post-intervention groups in terms of age (p > 0.49), gender (p = 0.51), or the number of patients who lacked capacity (p = 0.34). Following the implementation of the intervention strategy, there was a significant increase in the proportion of competent patients involved in their resuscitation decisions viz. pre-intervention 5% and post-intervention 34% (p = 0.02). Conclusion: Raising awareness of the latest DNACPR guidance through implementation of an educational programme and the use of an integrated care pathway significantly improved patient participation in this process. doi:10.1016/j.resuscitation.2010.09.461
doi:10.1016/j.resuscitation.2010.09.459
S113
Ethics
AP315
AP313
Characteristics of patients receiving do-not-attempt-resuscitation orders in a Brazilian tertiary hospital
Resuscitation in general medical wards: Who decides? DeKeyser Ganz
F. 1 ,
Israel
S. 1 ,
Hersch
M. 2 ,
Varon
J. 3 ,
Einav
Timermanthiago L.T., Timerman S., Quilici A.P., Gonzalez M.M., Ramires J.A. S. 2
1 MSc
Program, Hadassah Medical Centre School of Nursing, Jerusalem Israel 2 Intensive Care Unit, Shaare Zedek Hebrew University Medical Center, Jerusalem, Israel 3 University of Texas Health Science Center, Houston, Texas, USA Purpose: To investigate nurse experiences/attitudes regarding resuscitation with emphasis on intentional delay/avoidance of action. Methods: An anonymous questionnaire survey conducted among 122/142 nurses from five Medical wards in two Jerusalem hospitals. Results: Respondents were predominantly non-religious (n = 87, 74%) women (n = 93, 79%) under the age of 45 (n = 109, 87%) who had been CPR-certified within <2 years (n = 69, 63%). Most participated in >6 cardiopulmonary resuscitations in the past year (n = 72, 61%) and 95% had been the first on scene at least once (n = 113). Most respondents had participated in, or initiated, resuscitations they considered futile a-priori (n = 106, 89%; n = 104, 87%, respectively). Only half had been consulted by doctors regarding resuscitation in the past. Most felt they should be party to resuscitation decisions (n = 99, 84%). Several respondents had intentionally delayed (n = 22, 19%) or altogether avoided (n = 19, 16%) resuscitative actions. Some felt they are not professionally obligated to always initiate resuscitation (44%, n = 51) and some felt they may decide whether to initiate resuscitation or not despite written do not attempt resuscitation orders (32%, n = 37). Almost a third of the respondents considered intentional delay/non-initiation of resuscitation by the nurse permissible. Conclusions: Nurses act against their personal judgment in performing resuscitations they consider futile. They are often excluded from the resuscitation decision-making process despite their interest to participate. Delayed initiation/avoidance of resuscitation is considered allowable practice and is being actively practiced by some of these nurses. Nurses should be given the opportunity to voice their opinions regarding resuscitation lest they independently pre-empt medical resuscitation decisions. doi:10.1016/j.resuscitation.2010.09.458 AP314 Validation of the termination guideline for out of hospital arrest of Korea Eun J.G. 1 , Kwon M.K. 2 , Park Sh. 2 , Shin J.S. 2 , Kim M.J. 3 , Chung S.P. 3 , Lee H.S. 3 , Na J.U. 1 , Lee Y.H. 1 , Chang H.W. 1 , Shin T.G. 1 , Sim M.S. 1 , Jo I.J. 1 , Song H.G. 1 , Song K.J. 1 1 Department
of emergency medicine, Samsung Medical Center, Seoul, Korea Department of emergency medicine, Seoul Medical Center, Seoul, Korea 3 Department of emergency medicine, Gangnam Severance Hospital, Seoul, Korea 2
Purpose: Out-of-hospital cardiac arrest (OHCA) has low probability of survival to hospital discharge. According to multicenter study in Korea, survival to hospital discharge rate is 4.1%. Some of termination guidelines have been developed for use when resuscitation has no potential benefit for a victim. The BLS and ALS termination-of-resuscitation (TOR) rules revealed that it performed well in identifying patients with little or no chance of survival. There is no study about termination of resuscitation in Korea. So, we applied current using TOR rules to our OHCA patient data retrospectively, to validate appropriacy of BLS and ALS TOR rules in Korea. Materials and methods: We collected out of hospital arrest data from 3 hospitals in KOREA prehospital cardiac arrest registry between January 1, 2009, and December 31, 2009. And, for validation of the termination guideline, we applied BLS and ALS TOR rules derived from the OPALS (Ontario Prehospital Advanced Life Support) group’s large registry of cardiac arrest to these data retrospectively. We measure specificity and positive predictive value of each BLS and ALS TOR rule. Results: Total 131 cases were enrolled. The overall rate of survival to hospital discharge was 14.5% (n = 19). Of 102 patients who met BLS criteria TOR rules, 8 patients (7.8%) survived to hospital discharge. Of 52 patients who met ALS criteria TOR rules, 4 patients (7.7%) survived to hospital discharge. The BLS rule had a specificity of 0.57 (95% CI 0.33–0.79) and a positive predictive value of 0.92 (95% CI 0.85–0.97). The ALS rule had a specificity of 0.78 (95% CI 0.54–0.93) and positive predictive value of 0.92 (95% CI 0.81–0.97). Conclusions: In this study, the BLS and ALS TOR rules had relative low positive predictive value and did not performed in identifying patients with little chance of survival in KOREA. Further research about termination-of-resuscitation is needed regarding environment in Korea.
Laboratory of Emergency Cardiology Simulation, Heart Institute-InCor, Brazil Background: Do-not-attempt-resuscitation (DNAR) orders are common in hospitalized patients, however, both the epidemiological characteristics of this population and the association between the DNR orders and the level of measurable sickness are not well established. Methods: Charts from 337 consecutive patients who received a DNAR order were reviewed (July 2004 to September 2005). Variables studied included age, gender, comorbidities, major and secondary diagnosis, previous cardiac arrest (CA), Ejection fraction, site of CA, use of vasoactive drugs and orotracheal intubation, which were collected after the arrest. Results: The three most common comorbidities present before hospitalization were hypertension (46.6%), diabetes (27.6%) and chronic renal failure (23.4%), followed by previous stroke (13.9%), coronary artery disease (12.8%), dyslipidemia (11.6%) and Chagas cardiomiopathy (7.1%). No previous CA was found in 81.3% of the subjects who received the DNAR order, while 1, 2, 3 and 4 arrests were found in 13.4%, 3.3%, 1.8% and 0.3%, respectively. Most patients were admitted into the hospital with a diagnosis of Cardiovascular Disease (67.1%), Pulmonary Disease (14.9%) and Stroke (5.4%). Final diagnosis of infectious disease was present in 63.9%. Ejection fraction was normal in 1.2% of individuals, while mild (14.5%), moderate (37.1%) and severe (47.2%) dysfunction were observed in the remaining. During the stay, 13.6% presented Respiratory Distress, 69.1% with Acute Renal Failure, 88% with Shock of any cause, 90.9% needed support with vasoactive drugs and 94.3% were already intubated at the time of cardiac arrest. The average hospitalization time was 33 days. The most common site of arrest was the ICU, with 56.6% of the patients, followed by the Coronary Unit (22%) and the Emergency Room (17.5%). Conclusion: This data indicates that illness severity, present in patients receiving a DNAR order from this tertiary cardiology hospital, combined with family willingness seems to direct the decision to not attempt resuscitation. doi:10.1016/j.resuscitation.2010.09.460 AP316 ‘Do not attempt cardiopulmonary resuscitation’ orders: A transition from medical beneficence to patient autonomy Garbharran U. 1,2 , Chandarana K. 1,2 1 Elderly 2
Care Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Royal College of Physicians (London)
Purpose of the study: The British Medical Association, Resuscitation Council (UK) and Royal College of Nursing recommend that ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders should be discussed with all competent patients. However there is poor compliance with this guidance in the UK. Our aim was to assess whether this practice could be positively influenced by an intervention strategy at the Kent & Canterbury Hospital (KCH). This strategy was aimed at the multidisciplinary team to raise awareness of DNACPR guidelines thereby increasing patient participation. Materials and methods: On a randomly selected date, all DNACPR orders at the KCH were prospectively surveyed. Based on these findings, an education programme was implemented for junior doctors, consultant physicians and nurses. In addition, an integrated care pathway was developed and displayed on all wards. Consultant physicians were encouraged to consider DNACPR decisions on all patients at the point of admission using a checklist. Nine months following the above interventions, a further survey of DNACPR orders was performed. Results: The number of DNACPR orders surveyed pre- and post-intervention was 40 (19 men and 21 women, mean age 83) and 41 (26 men and 15 women, mean age 82), respectively. Eight patients lacked capacity and were excluded from further analysis. There was no significant difference between the pre- and post-intervention groups in terms of age (p > 0.49), gender (p = 0.51), or the number of patients who lacked capacity (p = 0.34). Following the implementation of the intervention strategy, there was a significant increase in the proportion of competent patients involved in their resuscitation decisions viz. pre-intervention 5% and post-intervention 34% (p = 0.02). Conclusion: Raising awareness of the latest DNACPR guidance through implementation of an educational programme and the use of an integrated care pathway significantly improved patient participation in this process. doi:10.1016/j.resuscitation.2010.09.461
doi:10.1016/j.resuscitation.2010.09.459