'Do not resuscitate' decision recorded for only 1 in 5 very sick older patients, study finds

Only around 1 in 5 very sick older patients has a 'do not resuscitate' decision recorded at the time of their emergency admission to hospital, reveals a study at one large UK hospital and published online in the journal BMJ Supportive & Palliative Care.

This is despite their being at high risk of cardiorespiratory arrest (when the heart and breathing stop) and the fact that resuscitation attempts are invasive and usually unsuccessful in these patients.

They need earlier opportunities to discuss the issues, say the researchers.

A decision not to attempt cardiopulmonary resuscitation (CPR) in the event of cardiorespiratory arrest requires a discussion between the doctor and the patient and/or their relatives.

If it is decided that CPR is not to be used, this 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision must be recorded and made available to all relevant healthcare professionals, usually on a special form.

The researchers therefore wanted to find out how many older patients admitted to acute medical wards at their hospital had a pre-existing DNACPR decision; how many had one recorded on the ward after admission; and how many of those who died already had a DNACPR decision in place.

They scrutinized the medical records of 481 patients aged 65 and older who were admitted consecutively to any of the six acute medical wards of one major UK teaching hospital between May and June 2017.

The average age of these patients was 82 and 208 (43%) were women. The average number of coexisting conditions was 5, and on average they were on 8 prescription drugs.

Just 1 in 5 (105/481; 22%) patients had a DNACPR decision recorded in their medical records on arrival at the ward; 30 had been made en route to the ward from emergency care.

Thirty four had been recorded during a previous hospital admission and 41 had been completed by the patient's family doctor.

Discussions about CPR took place on the ward for 48 (13%) of the remaining 376 patients: 16 of these discussions were with patients alone; 30 with relatives alone; and two with both.

These resulted in an additional 43 DNACPR decisions. An additional two decisions were made without discussion, both of which were for patients with severe cognitive impairment whose relatives weren't available.

Nearly 1 in 10 (37; 8%) patients died. All but one of these had a DNACPR decision in place. But most (20/36) of these decisions had been recorded during the hospital admission: 8 in the emergency unit and 12 on the acute medical ward itself.

Among the 20 dead patients whose DNACPR decision was recorded during their admission, the average time from the decision to death was 4 days with 7/20 (35%) made the day before the patient's death.

This is an observational study. It reflects experience at just one hospital in England and relied on records only up to 28 days after admission to hospital.

Nevertheless, comment the researchers: "These findings indicate a low rate of decision-making about the use of CPR other than in the context of an acute admission.

"Older patients with multimorbidity are not only at increased risk of receiving CPR but also high users of healthcare. It is therefore likely that many opportunities to address the issue of CPR in the non-acute setting have been missed," they write.

"While the need to make a decision about CPR may only become pressing during an acute episode of illness requiring medical admission, it is generally accepted that this is not the best time or place for the important discussion about CPR to be held," they add.

They highlight that: "CPR is an invasive and potentially undignified procedure from which older patients with multimorbidity are unlikely to have a good outcome; most older patients who receive CPR in hospital die before discharge."

A change in practice is needed, they conclude. "This…is only likely to come about by education of doctors and by education of the public so that all concerned understand the reality of CPR and the need to discuss its role well before it is needed."