- Email: [email protected]
Pre-printed ‘Do Not Attempt Resuscitation’ forms improve documentation?
Resuscitation 59 (2003) 89 /95 www.elsevier.com/locate/resuscitation
Pre-printed ‘Do Not Attempt Resuscitation’ forms improve documentation? Nick Castle a,b,*, Robert Owen b, Gary Kenward a, N. Ineson a,c a
b
Nurse Consultant in Emergency Care, Frimley Park hospital, Portsmouth Road, Camberley, Surrey, UK Department of Emergency Medical Care and Rescue, Durban Institute of Technology, Durban, South Africa c The Royal Defence Medical College, Birmingham, UK Received 5 March 2003; received in revised form 10 April 2003; accepted 24 April 2003
Abstract Objective: Do not-attempt-resuscitate orders are fundamental for allowing patients to die peacefully without inappropriate resuscitation attempts. Once the decision has been made it is imperative to record this information accurately. However, during a related research projected we noted that documentation was poor and we thought that the introduction of a pre-printed Do Not Attempt Resuscitation (DNAR) form would improve the documentation process. Design: Two sets of identical research questions were applied retrospectively, 12-months apart, to notes of adult patients ( /18 years) who had died during a hospital admission without under-going a resuscitation attempt. Between the first and the second audit, a new resuscitation policy that incorporated a pre-printed DNAR form was introduced into our hospital. Results: A pre-printed DNAR form improved documentation when measured against; clarity of DNAR order (P/0.05), date decision was made/implementation (P/0.014), presence of clinician’s signature (P/0.001), identification of the senior clinician making the decision (P 5/0.001) and justification for the DNAR decision (P 5/0.001). However, the pre-printed form made little improvement in encouraging patient involvement in the DNAR decisionmaking process (P/0.348). Conclusion: A pre-printed DNAR form can improve documentation significantly but it has little effect in encouraging patient involvement in the decision-making process. # 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Do Not Attempt Resuscitation (DNAR); Patient involvement; Pre-printed form
Resumo Objectivos: As ordens para na˜o tentar (DNAR) reanimar sa˜o indispensa´veis para permitir que os doentes morram em paz. Uma vez instituı´da esta determinac¸a˜o e´ imprescindı´vel regista´-la de forma apropriada. Contudo, ao investigar o processo notamos que a documentac¸a˜o era pobre e pensamos que a introduc¸a˜o de um formula´rio ordens para na˜o tentar (DNAR) pre´ impresso poderia melhorar poderia melhorar a documentac¸a˜o do processo clı´nico. Desenho: foram analisadas retrospectivamente duas se´ries de questo˜es incidindo sobre os processo de / 18anos que morreram durante a hospitalizac¸a˜o e nos quais na˜o foi tentada a reanimac¸a˜o. Entre a primeira e segunda auditoria implantou-se uma nova polı´tica de reanimac¸a˜o no nosso hospital, que incluı´a DNAR pre´-impressas. Resultados: As DNAR pre´-impressas melhorou a documentac¸a˜o avaliada por: clareza da DNAR (p 5/ 0,005), data em que a decisa˜o / implementac¸a˜o foi instituı´da (p / 0,014), existeˆncia de assinatura do clı´nico se´nior (p / 0,001), identificac¸a˜o do me´dico se´nior que tomou a decisa˜o (p B/ 0,001) e justificac¸a˜o para a DNAR (p B/ 0,001): contudo, a DNSAR pre´ impressa aumentou pouco a percentagem de doentes envolvidos na decisa˜o (p / 0,348). Concluso˜es: as ordens de DNAR pre´ impressas melhoram significativamente a documentac¸a˜o mas teˆm pouca influeˆncia no aumento do envolvimento dos doentes no processo de decidir. # 2003 Elsevier Ireland Ltd. All rights reserved. Palavras chave: Ordens para na˜o tentar (DNAR); Envolvimento do doente; Formula´rios pre´ impressos
* Corresponding author. Tel.: /44-1276-60-4604. E-mail address: [email protected] (N. Castle). 0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0300-9572(03)00176-X
90
N. Castle et al. / Resuscitation 59 (2003) 89 /95
Resumen Objetivos : Las o´rdenes de no intentar reanimacio´n son fundamentales para permitir a los pacientes morir pacı´ficamente sin intentos inapropiados de reanimacio´n. Una vez que se ha tomado la decisio´n es imperativo registrar esta informacio´n con precisio´n. Sin embargo, durante una investigacio´n relacionada proyectada, notamos que la documentacio´n era pobre y pensamos que la introduccio´n de un formulario pre impreso de ‘No Intentar Reanimacio´n’ (DNAR) mejorarı´a el proceso de documentacio´n. Disen˜o : Se aplicaron retrospectivamente dos conjuntos de preguntas de investigacio´n ide´nticos, separados 12 meses, de las notas de pacientes adultos (/18 an˜os) quienes murieron durante su estadı´a hospitalaria sin ser objeto de intento de reanimacio´n. Entre la primera y segunda evaluacio´n, se introdujo una nueva polı´tica de reanimacio´n que introducı´a un formulario de DNAR pre impreso. Resultados : Un formulario pre impreso de DNAR mejoro´ la documentacio´n al compararlo en: claridad de la orden de DNAR (P / 0.05), fecha en que se tomo´ la decisio´n / implementacio´n (P / 0.014), presencia de la firma del clı´nico ( P / 0.001), identificacio´n del clı´nico mayor que toma la decisio´n (P B0.001) y justificacio´n de la decisio´n de DNAR (P B0.001). Sin embargo, el formulario pre impreso mejoro´ muy poco en lo que concierne involucrar al paciente en el proceso de toma de decisio´n de DNAR (P / 0.348).Conclusio´n : Un formulario pre impreso de DNAR puede mejorar significativamente la documentacio´n pero tiene poco efecto en fomentar el involucrar al paciente en el proceso de toma de decisio´n. # 2003 Elsevier Ireland Ltd. All rights reserved. Palabras clave: No intente reanimacio´n (NIR); Involucrar al paciente; Formulario pre impreso
1. Introduction The decision to withhold cardio-pulmonary resuscitation is fraught with difficulties and in the United Kingdom (UK) has become a political issue following a number of high profile Do Not Attempt Resuscitation (DNAR) decisions [1 /3]. A number of influential groups, primarily representing the elderly [4], have become involved demanding that DNAR decision and the process surrounding how these decisions are made be open to greater scrutiny [5]. This is supported by formal instruction from the Chief Medical Officer in the Department of Health in the UK [6]. Increasing political pressure, supported by advice from the Chief Medical Officer, resulted in an edict from the Department of Health outlining a nationwide DNAR policy [7]. All hospitals in the UK were subsequently instructed to review their DNAR policy, and to assist in this process, the British Medical Association (BMA), the Royal College of Nursing (RCN) and the Resuscitation Council UK (RC(UK)) up-dated their previously published guidance documents [8]. Frimley Park Hospital had revised it’s DNAR policy in-line with best recommended practice and, although the decision making process was considered robust, concerns remained about the quality of documentation. It had been noted previously during an ongoing research project into the prevention of cardiac arrest that only 11.5% of patient who died underwent a resuscitation attempt, equating to a DNAR rate of 88.5% during 1999 [9]. Our DNAR rate of 88.5% is in-line with other published DNAR rates of between 75 and 90% [10,11] but is much higher than the rate identified by Layson et al. [12]. Steen [13] quotes the work by Layson et al. [12]
to highlight the generally low DNAR rate in some countries/institutions. Furthermore our reported cardiac arrest rate per 1000 admissions of 3.3% is well within the recently reported range by Weerasinghe et al. (1.65/1000 /4.75/1000) based on a review of all in-patient cardiac arrests for the Australian health district of New South Wales [14]. During research into the prevention of cardiac arrest an expert panel [9] noted that a small number of patients who had been resuscitated should have been considered for a DNAR order (unpublished data) [15]. It, therefore, appears that in general our DNAR decisions, when made, were appropriate although a small number of other patients required further consideration of their suitability for cardio-pulmonary resuscitation. The principle objective of this paper was to note the quality of DNAR documentation in the presence of a well-established DNAR policy. Other papers have identified that poor documentation of DNAR decisions can be problematic [16]. Concerns about the general standard of medical record keeping have also been widely reported [17 /20]. Substandard record keeping can lead directly to medico-legal action [20,21] or make decisions made in good faith more difficult to defend.
2. Methods 2.1. Population and location Frimley Park Hospital is a medium size hospital with 700 in-patient beds including an eight-bedded coronary care unit, nine-bedded intensive care/high dependency unit, and an emergency room that treated 75 684 patients during 2001. The hospital provided in-patient care for 53 146 patients as well as care for 217 178
N. Castle et al. / Resuscitation 59 (2003) 89 /95
outpatients during 2001. The hospitals activity, size and catchment area has changed little between the two audit dates.
2.2. Audit process This was a retrospective audit involving the medical notes of all patients who died at the hospital during a 1week period in July 2001 with the process being repeated for the same period 1-year later. All patients over the age of 18 years were included unless they had experienced a period of active resuscitation. Audit questions were agreed with both the hospital’s risk management and audit departments and ratified by the director of nursing (Table 1). Ethical committee approval was not sought as this was a retrospective audit of the DNAR documentation process. The aim of the first audit was to identify a baseline standard of documentation and to highlight areas for improvement. Soon after the first audit a pre-printed DNAR form was introduced along with educational support for staff. The second audit compared the standard of documentation before and after the preprinted DNAR form and education was introduced. A one-year gap was left between audits to allow for the newly introduced pre-printed DNAR form to become part of established hospital practice. This was based upon anecdotal experience that newly introduced policies require a period of regular practice before being assessed.
2.3. Statistical analysis The data was coded and analysed with the Statistical Package for the Social Sciences (SPSS) version 11.0. Proportions were compared using Pearson’s Chisquared (x2) test for independence and where categories contained less than five Fishers Exact test was applied. A ‘P ’ value of less than 0.05 was considered statistically significant. Confidence intervals could not be generated because the data collected was nominal (categorical) in nature, producing a Yes/No answer that does not support the application of confidence intervals. Table 1 Research questions (1) Was the DNAR decision clearly recorded in the patient’s notes without the use of code? (2) Was the date that the DNAR decision was made clearly recorded? (3) Was the DNAR order signed? (4) Was the clinician recording the DNAR orders clearly visible by name and by grade (e.g. was name printed)? (5) Was a reason for the DNAR decision given? (6) Was the patient involved in the decision making process?
91
2.4. Documentation process The previously established method of recording DNAR decisions was usually via a coded entry (e.g. not for 333, the hospital emergency number) being recorded on the inside cover of the patient’s notes or occasionally within the main-body of the patient’s clinical notes. The DNAR decision was also recorded occasionally within the nursing notes either as a handwritten entry or using a pre-printed highly visible adhesive sticker. The DNAR decision-making process was limited to doctors with full General Medical Council registration but any team member could complete the DNAR form as long as the name of the senior clinician making the decision was clearly identifiable. Following the initial audit, the hospital’s medical director instructed that the pre-printed DNAR form be introduced and the previously established documentation process should stop.
3. Education process As part of the introduction of our pre-printed DNAR form a briefing document was produced and added to our junior doctor’s induction package. The process surrounding DNAR decisions was also included in qualified nursing staff basic life support training. All admitting consultants and each ward/department manager received a copy of both the up-dated DNAR policy and the pre-printed form. In addition, a number of copies of the DNAR policy (and pre-printed form) were placed in the hospital library and the postgraduate medical education centre as well as being published on the hospitals intra-net. All senior hospital staff were given ample opportunity to provide feedback to the medical director with regard to the new DNAR policy and the associated change in the documentation process. No changes were put forward by the consultants or other bodies within the hospital, and therefore, the new policy was ratified by both the executive board and the consultant staff committee and was instigated from August 2001. Our approach placed great emphasis on ward-based nursing staff to ensure that accurate documentation was undertaken, particularly in the immediate period following junior doctor rotation.
4. Results There were 17 patients identified in the first audit (July 2001) and 20 patients in the second (July 2002). Following introduction of the pre-printed form, we noted a statically significant improvement in the follow-
92
N. Castle et al. / Resuscitation 59 (2003) 89 /95
ing key areas: clarity of DNAR statement (P /0.05), the date the decision was made/implemented (P /0.014), the presence of a clinician’s signature (P /0.001), identification of the senior clinician making the decision (P 5/0.001) and justification for the DNAR decision (P 5/0.001). The sixth key area, involvement of the patient in the decision making process, demonstrated a slight but non-statistically significant improvement (P / 0.348). It is noteworthy that relative involvement in the decision making process surrounding DNAR has remained unchanged (P /1.0) between the two audits despite improved documentation and the lack of any formal legal role for relatives with regards DNAR within the UK [6,22]. The role of relatives is limited to stating what a patient would wish and this is clearly highlighted within both our local as well as the national DNAR policy [8].
5. Changes to pre-printed DNAR form Following a notes review and discussion with both junior doctors and ward nurses, it was decided to change the wording on the pre-printed DNAR form with regards to communication with relatives. The aim was to change the process from a passive process of passing information to an active process of informing relatives of the medical decision that had been made. This involved changing the statement of ‘discuss with nextof-kin/significant other’ to ‘inform next-of-kin/significant other’. This decision was aimed at emphasising the role of the clinician in making the DNAR order and to deemphasise the role of relatives. This change was instigated following reports from senior nurses that medical staff were delaying recording appropriate DNAR decisions until it had been discussed with relatives.
6. Discussion As can be seen by a direct comparison of the two different sets of data (Fig. 1) significant improvements where made in five-out-of-the-six key areas following the introduction of the pre-printed DNAR form supported by education. However, no statistically significant improvement was noted with regards patient involvement nor was any significant change noted with regards the role of the next-of-kin. The keys to the successful implementation of the new policy and the associated pre-printed DNAR form were the senior ward-based nursing staff, who provided continued support to medical staff and the hospital
consultant body who retained overall responsibility for decisions made in their name [6 /8]. An area where the ‘pre-printed form’ made no statistically significant improvement was the involvement of patients within the decision-making process as out-lined in the BMA/RCN/RC(UK) DNAR guidelines [8] and the European Human Rights act [23]. This lack of communication had been the catalyst for the nationwide edict from the Department of Health [7] following a number of high-profile cases in the media [1,3,4]. We noted that only 1 out of 16 patients were involved in the decision-making process prior to the introduction of a pre-printed DNAR form and that this increased to only 4 out-of 20 patients following the introduction of the pre-printed form (P /0.348). Our experiences regarding the lack of patient involvement in decision-making is not unique, having been highlighted by other authors [24]. Smith et al. noted that less than 50% of doctors in his study were aware of the patient’s wishes regarding DNAR decisions. The main reasons given for a lack of formal doctor-patient discussion was the time such discussions required [24]. Fukaura and colleagues noted that in Japan only 5% of patients were involved in DNAR decisions and that typically a patient surrogate (usually a family member) was consulted regardless of the competency of the individual patient [25]. The data presented by Fukaura et al. serves to highlight the different cultural issues surrounding DNAR decision-making and patient involvement [25]. The role of surrogates appears to differ from country to country with Europe placing little store in their role (outside of stating what a patient may have wanted) through to formal protection in law in other countries such as Japan and some American states [25 /27]. It is noteworthy that under English law, relatives have no authority to give consent but are only able to imply what the patient may have wanted [6,22]. It would seem that in practice relatives believe they have a greater say and as we have found during our audit, attending medical staff continue to empower relatives. The process of involving patients within the decision making process is open to debate. Ebrahim suggests free and open discussion with all patients and implies that a lack of patient involvement is unethical [28]. However, other clinicians highlight that this may be a cruel and inhuman process leading to inappropriate resuscitation attempts [29,30]. The reasons for non-involvement of patients within the decision making process was not assessed during our audit. A number of suggestions have been proffered by clinicians, including a fear of upsetting patients [30,31], stereotyping [32], patients being too sick or unable to comprehend and time constraints [24]. Despite this it would appear that patients do wish to be involved in DNAR decisions [33] and clinical practice needs to
N. Castle et al. / Resuscitation 59 (2003) 89 /95
93
Fig. 1.
change to reflect this [34]. Many patients and relatives have exaggerated expectations regarding the success of resuscitation efforts [35,36]. Once they have been given a balanced explanation they are often able to make informed decisions [37]. It is also important that all parties realise that DNAR decisions do not necessarily
mean the withdrawal of active treatment and that many patients designated DNAR survive to leave hospital. As well as changing the wording on our DNAR preprinted form to emphasise the role of the patient and to downplay the role of relatives/surrogates it was proposed that a patient information leaflet be introduced.
94
N. Castle et al. / Resuscitation 59 (2003) 89 /95
Fig. 1 (Continued)
The BMA and the (RC(UK)) have produced a sample leaflet to assist with this process [38].
audit. Neither did we note if there was an increase in the number of DNAR orders made although this will be the subject of ongoing audit and clinical education.
7. Limitations of this study 8. Conclusion The small numbers of patients enrolled may affect the ability of this audit to generalise but it does give insight into the process. Despite this, statically significance was seen in five out-of-the six key audit questions. The small patients numbers were due to the audit being limited to a 1-week period. This was partly to ensure that medical staff did not become aware of the audit, and therefore, change how they documented DNAR decisions. No attempt was made to see if the DNAR decision was appropriate as this was not the purpose of this
DNAR orders are an established part of medical care as they facilitate the natural process of dying without aggressive medical intervention. This is particularly important when we consider the poor outcome associated with resuscitation that is further compounded by the costs associated with futile resuscitation attempts. Once the decision has been made, it is imperative that both the decision, and any associated rationale, is carefully and accurately recorded so as to minimise errors. We have found that a structured DNAR form
N. Castle et al. / Resuscitation 59 (2003) 89 /95
will aid the documentation process and improve communication between health care professionals but it had little impact with regard to increasing patient involvement in DNAR decisions.
References [1] Cancer patient’s fury at doctor who wrote her off on hospital’s death Ward’, The Guardian, 13 April 2000. [2] Munro R. A heart-stopping moment. Nurs Times 2000;96:12. [3] Communication surrounding a decision not to resuscitate a patient-W258/89-90. In: Report of the Health Service Commissioner, 1990/1991. London: HMSO, 1991. p. 12. [4] Age Concern England. Turning your back on us */older people and the NHS. London: Age Concern, 2000. [5] The beginning of the end to the scandal of ‘Not for resuscitation’. Age concern England. Astral House, 1268 London Road, London, 2001. [6] Chief Medical Officer. Letter to all consultants on resuscitation policy. London: Department of Health, 1991 (PL/CM0(91)22). [7] NHS Executive Resuscitation policy (HSC 2000/028) September 2000 (England). Scottish Executive Health Department Resuscitation policy (HDL 2000/22). Edinburgh Scottish Executive, November 2000. [8] British Medical Association, Resuscitation Council (UK), Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation: a joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. J Med Ethics 2001;27:310 /6. [9] Hodgetts JT, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, Ineson N, Shaikn L. Incidence, location and reasons for avoidable Cardiac arrest in a district general hospital. Resuscitation 2002;54:115 /23. [10] Bedell SE, Pelle D, Maher PL, Cleary PD. Do not resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact. J Am Med Assoc 1986;256:233 /7. [11] Skogvoll E, Isern E, Sangolt GK, Gisvold SE. In-hospital cardiopulmonary resuscitation. 5 years incidence and survival according to the Utstein template. Acta Anaesthesiol Scand 1999;43:177 /84. [12] Layson RT, Adelman HM, Wallach PM, Pfeifer MP, Johnston S, McNutt RA. Discussion about the use of life-sustaining treatments: a literature review of physicians’ and patients’ attitudes and practices. End of Life Study Group. J Clin Ethics 1994;5:195 /203. [13] Steen PA. Letter to the Editor. Resuscitation 2002;55:349. [14] Weerasinghe DP, MacIntyre RC, Rubin GL. The epidemiology of cardiac arrests in a Sydney hospital. Resuscitation 2002;53:53 /62. [15] Hodgetts, JT, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, Ineson N, Shaikn L. Unpublished data. [16] Wynne G, Owen R, Evans T. Haphazard documentation of do not attempt resuscitation (DNAR) orders. Resuscitation 1998;37:S53.
95
[17] Chua RV, Cordell WH, Ernsting KL, Bock HC, Nyhuis AW. Accuracy of bar codes versus handwriting for recording trauma resuscitation events. Ann Emer Med 1993;22:1545 /50. [18] Bateman ND, Carney AS, Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J R Coll Surg Edinburgh 1999;44:94 /5. [19] Sanghavi R, Shefler A. The ABCs of recording paediatric cardiac arrests. Resuscitation 2002;55:167 /70. [20] Lesar T, Briceland L, Stein DS. Factors related to errors in medication prescribing. J Am Med Assoc 1997;277:312 /7. [21] Marsh B, Narain J. Patient dies because of GP’s bad handwriting, Daily Mail 4 February 2003;35. [22] Dimond B. Legal aspects of nursing 2nd. London: Prentice Hall, 1994. [23] Humans Rights Act, 1998. The Stationary Office October 2000. [24] Smith TJ, Desch CE, Hackney MH, Shaw JE. How long does it take to get a ‘do not resuscitate’ order. J Palliat Care 1997;13:5 /8. [25] Fukaura A, Tazawa H, Nakajima H, Adachi M. Do-notresuscitate orders at a teaching hospital in Japan. New Engl J Med 1995;333:805 /8. [26] Haverkate I, van Delden JJM, van Nijen AB, van der Wal G. Guidelines for the use of do-not-resuscitate orders in Dutch hospital. Crit Care Med 2000;28:3039 /43. [27] Mellor M, Jenkinson C. Comparison of medical and nursing attitudes to resuscitation and patient autonomy between a British and American teaching hospital. Soc Sci Med 1998;46:415 /24. [28] Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death?: resuscitation should not be withheld from elderly people without discussion. Br Med J 2000;320:1155 /6. [29] Tunstall-Pedoe H. Do not resuscitate decisions: resuscitation should not be part of every death. Br Med J 2001;322:102. [30] Smith G. Do not resuscitate decisions: sound clinical reasons for withholding cardiopulmonary resuscitation must not be confused with ageism. Br Med J 2001;322:104. [31] Matthews E. Can paternalism be modernized. J Med Ethics 1986;12:133 /5. [32] Thompson BL, Lawson D, Croughan-Minihane M, Cooke M. Do patients’ ethnic and social factors influence the use of do-notattempt-resuscitate orders. Ethn Dis 1999;9:132 /9. [33] Bruce-Jones P, Roberts H, Bowker L. Resuscitating the elderly: what do the patients want. J Med Ethics 1996;22:154 /9. [34] Say when you want to die, patients asked. Daily Mail 24 February 2003;15. [35] Miller DL, Jahnigen DW, Gorbien MJ. Cardiopulmonary resuscitation: how useful? Attitudes and knowledge of an elderly population. Arch Intern Med 1992;152:578 /82. [36] Murphy GJ, Burrows D, Santilli S. The influence of the probability of survival on patients’ preferences regarding pulmonary resuscitation. New Engl J Med 1994;330:545 /9. [37] Walker RM, Schonwetter RS, Kramer DR. Living wills and resuscitation preferences in an elderly population. Arch Intern Med 1995;155:171 /5. [38] Decisions relating to cardiopulmonary resuscitation: model information leaflet. London: BMA, 2002. Available on http:// www.resus.org.uk.
Pre-printed ‘Do Not Attempt Resuscitation’ forms improve documentation? Nick Castle a,b,*, Robert Owen b, Gary Kenward a, N. Ineson a,c a
b
Nurse Consultant in Emergency Care, Frimley Park hospital, Portsmouth Road, Camberley, Surrey, UK Department of Emergency Medical Care and Rescue, Durban Institute of Technology, Durban, South Africa c The Royal Defence Medical College, Birmingham, UK Received 5 March 2003; received in revised form 10 April 2003; accepted 24 April 2003
Abstract Objective: Do not-attempt-resuscitate orders are fundamental for allowing patients to die peacefully without inappropriate resuscitation attempts. Once the decision has been made it is imperative to record this information accurately. However, during a related research projected we noted that documentation was poor and we thought that the introduction of a pre-printed Do Not Attempt Resuscitation (DNAR) form would improve the documentation process. Design: Two sets of identical research questions were applied retrospectively, 12-months apart, to notes of adult patients ( /18 years) who had died during a hospital admission without under-going a resuscitation attempt. Between the first and the second audit, a new resuscitation policy that incorporated a pre-printed DNAR form was introduced into our hospital. Results: A pre-printed DNAR form improved documentation when measured against; clarity of DNAR order (P/0.05), date decision was made/implementation (P/0.014), presence of clinician’s signature (P/0.001), identification of the senior clinician making the decision (P 5/0.001) and justification for the DNAR decision (P 5/0.001). However, the pre-printed form made little improvement in encouraging patient involvement in the DNAR decisionmaking process (P/0.348). Conclusion: A pre-printed DNAR form can improve documentation significantly but it has little effect in encouraging patient involvement in the decision-making process. # 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Do Not Attempt Resuscitation (DNAR); Patient involvement; Pre-printed form
Resumo Objectivos: As ordens para na˜o tentar (DNAR) reanimar sa˜o indispensa´veis para permitir que os doentes morram em paz. Uma vez instituı´da esta determinac¸a˜o e´ imprescindı´vel regista´-la de forma apropriada. Contudo, ao investigar o processo notamos que a documentac¸a˜o era pobre e pensamos que a introduc¸a˜o de um formula´rio ordens para na˜o tentar (DNAR) pre´ impresso poderia melhorar poderia melhorar a documentac¸a˜o do processo clı´nico. Desenho: foram analisadas retrospectivamente duas se´ries de questo˜es incidindo sobre os processo de / 18anos que morreram durante a hospitalizac¸a˜o e nos quais na˜o foi tentada a reanimac¸a˜o. Entre a primeira e segunda auditoria implantou-se uma nova polı´tica de reanimac¸a˜o no nosso hospital, que incluı´a DNAR pre´-impressas. Resultados: As DNAR pre´-impressas melhorou a documentac¸a˜o avaliada por: clareza da DNAR (p 5/ 0,005), data em que a decisa˜o / implementac¸a˜o foi instituı´da (p / 0,014), existeˆncia de assinatura do clı´nico se´nior (p / 0,001), identificac¸a˜o do me´dico se´nior que tomou a decisa˜o (p B/ 0,001) e justificac¸a˜o para a DNAR (p B/ 0,001): contudo, a DNSAR pre´ impressa aumentou pouco a percentagem de doentes envolvidos na decisa˜o (p / 0,348). Concluso˜es: as ordens de DNAR pre´ impressas melhoram significativamente a documentac¸a˜o mas teˆm pouca influeˆncia no aumento do envolvimento dos doentes no processo de decidir. # 2003 Elsevier Ireland Ltd. All rights reserved. Palavras chave: Ordens para na˜o tentar (DNAR); Envolvimento do doente; Formula´rios pre´ impressos
* Corresponding author. Tel.: /44-1276-60-4604. E-mail address: [email protected] (N. Castle). 0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0300-9572(03)00176-X
90
N. Castle et al. / Resuscitation 59 (2003) 89 /95
Resumen Objetivos : Las o´rdenes de no intentar reanimacio´n son fundamentales para permitir a los pacientes morir pacı´ficamente sin intentos inapropiados de reanimacio´n. Una vez que se ha tomado la decisio´n es imperativo registrar esta informacio´n con precisio´n. Sin embargo, durante una investigacio´n relacionada proyectada, notamos que la documentacio´n era pobre y pensamos que la introduccio´n de un formulario pre impreso de ‘No Intentar Reanimacio´n’ (DNAR) mejorarı´a el proceso de documentacio´n. Disen˜o : Se aplicaron retrospectivamente dos conjuntos de preguntas de investigacio´n ide´nticos, separados 12 meses, de las notas de pacientes adultos (/18 an˜os) quienes murieron durante su estadı´a hospitalaria sin ser objeto de intento de reanimacio´n. Entre la primera y segunda evaluacio´n, se introdujo una nueva polı´tica de reanimacio´n que introducı´a un formulario de DNAR pre impreso. Resultados : Un formulario pre impreso de DNAR mejoro´ la documentacio´n al compararlo en: claridad de la orden de DNAR (P / 0.05), fecha en que se tomo´ la decisio´n / implementacio´n (P / 0.014), presencia de la firma del clı´nico ( P / 0.001), identificacio´n del clı´nico mayor que toma la decisio´n (P B0.001) y justificacio´n de la decisio´n de DNAR (P B0.001). Sin embargo, el formulario pre impreso mejoro´ muy poco en lo que concierne involucrar al paciente en el proceso de toma de decisio´n de DNAR (P / 0.348).Conclusio´n : Un formulario pre impreso de DNAR puede mejorar significativamente la documentacio´n pero tiene poco efecto en fomentar el involucrar al paciente en el proceso de toma de decisio´n. # 2003 Elsevier Ireland Ltd. All rights reserved. Palabras clave: No intente reanimacio´n (NIR); Involucrar al paciente; Formulario pre impreso
1. Introduction The decision to withhold cardio-pulmonary resuscitation is fraught with difficulties and in the United Kingdom (UK) has become a political issue following a number of high profile Do Not Attempt Resuscitation (DNAR) decisions [1 /3]. A number of influential groups, primarily representing the elderly [4], have become involved demanding that DNAR decision and the process surrounding how these decisions are made be open to greater scrutiny [5]. This is supported by formal instruction from the Chief Medical Officer in the Department of Health in the UK [6]. Increasing political pressure, supported by advice from the Chief Medical Officer, resulted in an edict from the Department of Health outlining a nationwide DNAR policy [7]. All hospitals in the UK were subsequently instructed to review their DNAR policy, and to assist in this process, the British Medical Association (BMA), the Royal College of Nursing (RCN) and the Resuscitation Council UK (RC(UK)) up-dated their previously published guidance documents [8]. Frimley Park Hospital had revised it’s DNAR policy in-line with best recommended practice and, although the decision making process was considered robust, concerns remained about the quality of documentation. It had been noted previously during an ongoing research project into the prevention of cardiac arrest that only 11.5% of patient who died underwent a resuscitation attempt, equating to a DNAR rate of 88.5% during 1999 [9]. Our DNAR rate of 88.5% is in-line with other published DNAR rates of between 75 and 90% [10,11] but is much higher than the rate identified by Layson et al. [12]. Steen [13] quotes the work by Layson et al. [12]
to highlight the generally low DNAR rate in some countries/institutions. Furthermore our reported cardiac arrest rate per 1000 admissions of 3.3% is well within the recently reported range by Weerasinghe et al. (1.65/1000 /4.75/1000) based on a review of all in-patient cardiac arrests for the Australian health district of New South Wales [14]. During research into the prevention of cardiac arrest an expert panel [9] noted that a small number of patients who had been resuscitated should have been considered for a DNAR order (unpublished data) [15]. It, therefore, appears that in general our DNAR decisions, when made, were appropriate although a small number of other patients required further consideration of their suitability for cardio-pulmonary resuscitation. The principle objective of this paper was to note the quality of DNAR documentation in the presence of a well-established DNAR policy. Other papers have identified that poor documentation of DNAR decisions can be problematic [16]. Concerns about the general standard of medical record keeping have also been widely reported [17 /20]. Substandard record keeping can lead directly to medico-legal action [20,21] or make decisions made in good faith more difficult to defend.
2. Methods 2.1. Population and location Frimley Park Hospital is a medium size hospital with 700 in-patient beds including an eight-bedded coronary care unit, nine-bedded intensive care/high dependency unit, and an emergency room that treated 75 684 patients during 2001. The hospital provided in-patient care for 53 146 patients as well as care for 217 178
N. Castle et al. / Resuscitation 59 (2003) 89 /95
outpatients during 2001. The hospitals activity, size and catchment area has changed little between the two audit dates.
2.2. Audit process This was a retrospective audit involving the medical notes of all patients who died at the hospital during a 1week period in July 2001 with the process being repeated for the same period 1-year later. All patients over the age of 18 years were included unless they had experienced a period of active resuscitation. Audit questions were agreed with both the hospital’s risk management and audit departments and ratified by the director of nursing (Table 1). Ethical committee approval was not sought as this was a retrospective audit of the DNAR documentation process. The aim of the first audit was to identify a baseline standard of documentation and to highlight areas for improvement. Soon after the first audit a pre-printed DNAR form was introduced along with educational support for staff. The second audit compared the standard of documentation before and after the preprinted DNAR form and education was introduced. A one-year gap was left between audits to allow for the newly introduced pre-printed DNAR form to become part of established hospital practice. This was based upon anecdotal experience that newly introduced policies require a period of regular practice before being assessed.
2.3. Statistical analysis The data was coded and analysed with the Statistical Package for the Social Sciences (SPSS) version 11.0. Proportions were compared using Pearson’s Chisquared (x2) test for independence and where categories contained less than five Fishers Exact test was applied. A ‘P ’ value of less than 0.05 was considered statistically significant. Confidence intervals could not be generated because the data collected was nominal (categorical) in nature, producing a Yes/No answer that does not support the application of confidence intervals. Table 1 Research questions (1) Was the DNAR decision clearly recorded in the patient’s notes without the use of code? (2) Was the date that the DNAR decision was made clearly recorded? (3) Was the DNAR order signed? (4) Was the clinician recording the DNAR orders clearly visible by name and by grade (e.g. was name printed)? (5) Was a reason for the DNAR decision given? (6) Was the patient involved in the decision making process?
91
2.4. Documentation process The previously established method of recording DNAR decisions was usually via a coded entry (e.g. not for 333, the hospital emergency number) being recorded on the inside cover of the patient’s notes or occasionally within the main-body of the patient’s clinical notes. The DNAR decision was also recorded occasionally within the nursing notes either as a handwritten entry or using a pre-printed highly visible adhesive sticker. The DNAR decision-making process was limited to doctors with full General Medical Council registration but any team member could complete the DNAR form as long as the name of the senior clinician making the decision was clearly identifiable. Following the initial audit, the hospital’s medical director instructed that the pre-printed DNAR form be introduced and the previously established documentation process should stop.
3. Education process As part of the introduction of our pre-printed DNAR form a briefing document was produced and added to our junior doctor’s induction package. The process surrounding DNAR decisions was also included in qualified nursing staff basic life support training. All admitting consultants and each ward/department manager received a copy of both the up-dated DNAR policy and the pre-printed form. In addition, a number of copies of the DNAR policy (and pre-printed form) were placed in the hospital library and the postgraduate medical education centre as well as being published on the hospitals intra-net. All senior hospital staff were given ample opportunity to provide feedback to the medical director with regard to the new DNAR policy and the associated change in the documentation process. No changes were put forward by the consultants or other bodies within the hospital, and therefore, the new policy was ratified by both the executive board and the consultant staff committee and was instigated from August 2001. Our approach placed great emphasis on ward-based nursing staff to ensure that accurate documentation was undertaken, particularly in the immediate period following junior doctor rotation.
4. Results There were 17 patients identified in the first audit (July 2001) and 20 patients in the second (July 2002). Following introduction of the pre-printed form, we noted a statically significant improvement in the follow-
92
N. Castle et al. / Resuscitation 59 (2003) 89 /95
ing key areas: clarity of DNAR statement (P /0.05), the date the decision was made/implemented (P /0.014), the presence of a clinician’s signature (P /0.001), identification of the senior clinician making the decision (P 5/0.001) and justification for the DNAR decision (P 5/0.001). The sixth key area, involvement of the patient in the decision making process, demonstrated a slight but non-statistically significant improvement (P / 0.348). It is noteworthy that relative involvement in the decision making process surrounding DNAR has remained unchanged (P /1.0) between the two audits despite improved documentation and the lack of any formal legal role for relatives with regards DNAR within the UK [6,22]. The role of relatives is limited to stating what a patient would wish and this is clearly highlighted within both our local as well as the national DNAR policy [8].
5. Changes to pre-printed DNAR form Following a notes review and discussion with both junior doctors and ward nurses, it was decided to change the wording on the pre-printed DNAR form with regards to communication with relatives. The aim was to change the process from a passive process of passing information to an active process of informing relatives of the medical decision that had been made. This involved changing the statement of ‘discuss with nextof-kin/significant other’ to ‘inform next-of-kin/significant other’. This decision was aimed at emphasising the role of the clinician in making the DNAR order and to deemphasise the role of relatives. This change was instigated following reports from senior nurses that medical staff were delaying recording appropriate DNAR decisions until it had been discussed with relatives.
6. Discussion As can be seen by a direct comparison of the two different sets of data (Fig. 1) significant improvements where made in five-out-of-the-six key areas following the introduction of the pre-printed DNAR form supported by education. However, no statistically significant improvement was noted with regards patient involvement nor was any significant change noted with regards the role of the next-of-kin. The keys to the successful implementation of the new policy and the associated pre-printed DNAR form were the senior ward-based nursing staff, who provided continued support to medical staff and the hospital
consultant body who retained overall responsibility for decisions made in their name [6 /8]. An area where the ‘pre-printed form’ made no statistically significant improvement was the involvement of patients within the decision-making process as out-lined in the BMA/RCN/RC(UK) DNAR guidelines [8] and the European Human Rights act [23]. This lack of communication had been the catalyst for the nationwide edict from the Department of Health [7] following a number of high-profile cases in the media [1,3,4]. We noted that only 1 out of 16 patients were involved in the decision-making process prior to the introduction of a pre-printed DNAR form and that this increased to only 4 out-of 20 patients following the introduction of the pre-printed form (P /0.348). Our experiences regarding the lack of patient involvement in decision-making is not unique, having been highlighted by other authors [24]. Smith et al. noted that less than 50% of doctors in his study were aware of the patient’s wishes regarding DNAR decisions. The main reasons given for a lack of formal doctor-patient discussion was the time such discussions required [24]. Fukaura and colleagues noted that in Japan only 5% of patients were involved in DNAR decisions and that typically a patient surrogate (usually a family member) was consulted regardless of the competency of the individual patient [25]. The data presented by Fukaura et al. serves to highlight the different cultural issues surrounding DNAR decision-making and patient involvement [25]. The role of surrogates appears to differ from country to country with Europe placing little store in their role (outside of stating what a patient may have wanted) through to formal protection in law in other countries such as Japan and some American states [25 /27]. It is noteworthy that under English law, relatives have no authority to give consent but are only able to imply what the patient may have wanted [6,22]. It would seem that in practice relatives believe they have a greater say and as we have found during our audit, attending medical staff continue to empower relatives. The process of involving patients within the decision making process is open to debate. Ebrahim suggests free and open discussion with all patients and implies that a lack of patient involvement is unethical [28]. However, other clinicians highlight that this may be a cruel and inhuman process leading to inappropriate resuscitation attempts [29,30]. The reasons for non-involvement of patients within the decision making process was not assessed during our audit. A number of suggestions have been proffered by clinicians, including a fear of upsetting patients [30,31], stereotyping [32], patients being too sick or unable to comprehend and time constraints [24]. Despite this it would appear that patients do wish to be involved in DNAR decisions [33] and clinical practice needs to
N. Castle et al. / Resuscitation 59 (2003) 89 /95
93
Fig. 1.
change to reflect this [34]. Many patients and relatives have exaggerated expectations regarding the success of resuscitation efforts [35,36]. Once they have been given a balanced explanation they are often able to make informed decisions [37]. It is also important that all parties realise that DNAR decisions do not necessarily
mean the withdrawal of active treatment and that many patients designated DNAR survive to leave hospital. As well as changing the wording on our DNAR preprinted form to emphasise the role of the patient and to downplay the role of relatives/surrogates it was proposed that a patient information leaflet be introduced.
94
N. Castle et al. / Resuscitation 59 (2003) 89 /95
Fig. 1 (Continued)
The BMA and the (RC(UK)) have produced a sample leaflet to assist with this process [38].
audit. Neither did we note if there was an increase in the number of DNAR orders made although this will be the subject of ongoing audit and clinical education.
7. Limitations of this study 8. Conclusion The small numbers of patients enrolled may affect the ability of this audit to generalise but it does give insight into the process. Despite this, statically significance was seen in five out-of-the six key audit questions. The small patients numbers were due to the audit being limited to a 1-week period. This was partly to ensure that medical staff did not become aware of the audit, and therefore, change how they documented DNAR decisions. No attempt was made to see if the DNAR decision was appropriate as this was not the purpose of this
DNAR orders are an established part of medical care as they facilitate the natural process of dying without aggressive medical intervention. This is particularly important when we consider the poor outcome associated with resuscitation that is further compounded by the costs associated with futile resuscitation attempts. Once the decision has been made, it is imperative that both the decision, and any associated rationale, is carefully and accurately recorded so as to minimise errors. We have found that a structured DNAR form
N. Castle et al. / Resuscitation 59 (2003) 89 /95
will aid the documentation process and improve communication between health care professionals but it had little impact with regard to increasing patient involvement in DNAR decisions.
References [1] Cancer patient’s fury at doctor who wrote her off on hospital’s death Ward’, The Guardian, 13 April 2000. [2] Munro R. A heart-stopping moment. Nurs Times 2000;96:12. [3] Communication surrounding a decision not to resuscitate a patient-W258/89-90. In: Report of the Health Service Commissioner, 1990/1991. London: HMSO, 1991. p. 12. [4] Age Concern England. Turning your back on us */older people and the NHS. London: Age Concern, 2000. [5] The beginning of the end to the scandal of ‘Not for resuscitation’. Age concern England. Astral House, 1268 London Road, London, 2001. [6] Chief Medical Officer. Letter to all consultants on resuscitation policy. London: Department of Health, 1991 (PL/CM0(91)22). [7] NHS Executive Resuscitation policy (HSC 2000/028) September 2000 (England). Scottish Executive Health Department Resuscitation policy (HDL 2000/22). Edinburgh Scottish Executive, November 2000. [8] British Medical Association, Resuscitation Council (UK), Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation: a joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. J Med Ethics 2001;27:310 /6. [9] Hodgetts JT, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, Ineson N, Shaikn L. Incidence, location and reasons for avoidable Cardiac arrest in a district general hospital. Resuscitation 2002;54:115 /23. [10] Bedell SE, Pelle D, Maher PL, Cleary PD. Do not resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact. J Am Med Assoc 1986;256:233 /7. [11] Skogvoll E, Isern E, Sangolt GK, Gisvold SE. In-hospital cardiopulmonary resuscitation. 5 years incidence and survival according to the Utstein template. Acta Anaesthesiol Scand 1999;43:177 /84. [12] Layson RT, Adelman HM, Wallach PM, Pfeifer MP, Johnston S, McNutt RA. Discussion about the use of life-sustaining treatments: a literature review of physicians’ and patients’ attitudes and practices. End of Life Study Group. J Clin Ethics 1994;5:195 /203. [13] Steen PA. Letter to the Editor. Resuscitation 2002;55:349. [14] Weerasinghe DP, MacIntyre RC, Rubin GL. The epidemiology of cardiac arrests in a Sydney hospital. Resuscitation 2002;53:53 /62. [15] Hodgetts, JT, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, Ineson N, Shaikn L. Unpublished data. [16] Wynne G, Owen R, Evans T. Haphazard documentation of do not attempt resuscitation (DNAR) orders. Resuscitation 1998;37:S53.
95
[17] Chua RV, Cordell WH, Ernsting KL, Bock HC, Nyhuis AW. Accuracy of bar codes versus handwriting for recording trauma resuscitation events. Ann Emer Med 1993;22:1545 /50. [18] Bateman ND, Carney AS, Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J R Coll Surg Edinburgh 1999;44:94 /5. [19] Sanghavi R, Shefler A. The ABCs of recording paediatric cardiac arrests. Resuscitation 2002;55:167 /70. [20] Lesar T, Briceland L, Stein DS. Factors related to errors in medication prescribing. J Am Med Assoc 1997;277:312 /7. [21] Marsh B, Narain J. Patient dies because of GP’s bad handwriting, Daily Mail 4 February 2003;35. [22] Dimond B. Legal aspects of nursing 2nd. London: Prentice Hall, 1994. [23] Humans Rights Act, 1998. The Stationary Office October 2000. [24] Smith TJ, Desch CE, Hackney MH, Shaw JE. How long does it take to get a ‘do not resuscitate’ order. J Palliat Care 1997;13:5 /8. [25] Fukaura A, Tazawa H, Nakajima H, Adachi M. Do-notresuscitate orders at a teaching hospital in Japan. New Engl J Med 1995;333:805 /8. [26] Haverkate I, van Delden JJM, van Nijen AB, van der Wal G. Guidelines for the use of do-not-resuscitate orders in Dutch hospital. Crit Care Med 2000;28:3039 /43. [27] Mellor M, Jenkinson C. Comparison of medical and nursing attitudes to resuscitation and patient autonomy between a British and American teaching hospital. Soc Sci Med 1998;46:415 /24. [28] Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death?: resuscitation should not be withheld from elderly people without discussion. Br Med J 2000;320:1155 /6. [29] Tunstall-Pedoe H. Do not resuscitate decisions: resuscitation should not be part of every death. Br Med J 2001;322:102. [30] Smith G. Do not resuscitate decisions: sound clinical reasons for withholding cardiopulmonary resuscitation must not be confused with ageism. Br Med J 2001;322:104. [31] Matthews E. Can paternalism be modernized. J Med Ethics 1986;12:133 /5. [32] Thompson BL, Lawson D, Croughan-Minihane M, Cooke M. Do patients’ ethnic and social factors influence the use of do-notattempt-resuscitate orders. Ethn Dis 1999;9:132 /9. [33] Bruce-Jones P, Roberts H, Bowker L. Resuscitating the elderly: what do the patients want. J Med Ethics 1996;22:154 /9. [34] Say when you want to die, patients asked. Daily Mail 24 February 2003;15. [35] Miller DL, Jahnigen DW, Gorbien MJ. Cardiopulmonary resuscitation: how useful? Attitudes and knowledge of an elderly population. Arch Intern Med 1992;152:578 /82. [36] Murphy GJ, Burrows D, Santilli S. The influence of the probability of survival on patients’ preferences regarding pulmonary resuscitation. New Engl J Med 1994;330:545 /9. [37] Walker RM, Schonwetter RS, Kramer DR. Living wills and resuscitation preferences in an elderly population. Arch Intern Med 1995;155:171 /5. [38] Decisions relating to cardiopulmonary resuscitation: model information leaflet. London: BMA, 2002. Available on http:// www.resus.org.uk.