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Invited Commentary
Emergency Medicine
June 7, 2019

Time to Change From Do-Not-Resuscitate Orders to Emergency Care Treatment Plans

Author Affiliations
  • 1Warwick Clinical Trials Unit, Warwick Medical School, Coventry, United Kingdom
  • 2University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
  • 3The Healthcare Improvement Studies Institute, Cambridge, United Kingdom
  • 4Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
JAMA Netw Open. 2019;2(6):e195170. doi:10.1001/jamanetworkopen.2019.5170

Cardiopulmonary resuscitation (CPR) is an invasive medical treatment. It was first used to treat patients whose hearts were too good to die. While it can be a life-saving intervention in that context, CPR is not an effective treatment for people who are approaching the end of their natural lives. Do-not-resuscitate (DNR) orders or code decisions provide a mechanism through which a preemptive decision can be made—usually with the patient—to withhold CPR in the event of a cardiac arrest. Broadly speaking, DNR decisions are appropriate when there is little or no chance that resuscitation will be successful, when the balance of burdens outweighs the benefits, or when a patient advises that they do not want to be resuscitated.1 A key requirement of effective patient-centered health care is the involvement of the patient in decision making. It is therefore timely that Becker et al2 report findings from a systematic review and meta-analysis of communication interventions to aid resuscitation decisions and explore their association with patient decisions and knowledge about DNR orders. The review by Becker et al2 draws on evidence from 15 randomized clinical trials involving 2405 adult patients, mostly in a US setting. Most (11) trials included a video; others provided written material, structured discussions, or counseling. The meta-analysis of 11 randomized clinical trials by Becker et al2 found that communication interventions reduced patient preferences for CPR from 53.6% to 38.6% (risk ratio, 0.70; 95% CI, 0.63-0.78) and improved patients’ knowledge about CPR treatment. Subgroup analyses identified that video-assisted decision aids were most effective in achieving these outcomes. Interventions worked better among older patients, men, and those with lower literacy. Becker et al2 suggest that these interventions improve knowledge, thereby enabling patients to actively participate in the decision-making process.

Making decisions about CPR more patient centered is a worthy goal; for decades, these decisions were hidden or talked about in code,3 and as Becker et al2 reference, discussions are still often avoided or done badly. Part of clinicians’ reluctance to discuss CPR with patients may stem from a widely acknowledged problem with the interpretation of DNR documentation. In a 2016 review of DNR decisions across the United Kingdom,3 a key concern reported by clinicians was the perception that DNR decisions were being misinterpreted to mean do not provide any treatment. An accompanying systematic review of international studies4 found that DNR decisions were associated with fewer invasive medical treatments, reduced escalation to medical and intensive care staff in the event of deterioration, fewer nursing observations, and less robust basic care, including less pain relief and altered fluid intake.

Linking discussions about resuscitation with decisions about other aspects of emergency care and treatment helps to provide greater clarity about the goals of care, can aid communication among clinicians, and may reduce the harms identified from decisions that focus only on withholding resuscitation.5 In the UK health setting, the Resuscitation Council (UK) established the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT).6 This facilitates personalized recommendations for clinical care in a future emergency (including resuscitation) in the situation that the patient is unable to make or express choices. It provides health care professionals with a summary of recommendations to help them make immediate decisions about that person’s care and treatment. Similar, patient-focused systems that encourage dialogue between patients and clinicians to formulate overall treatment plans have been growing across North America (eg, Physician Orders for Life Sustaining Treatment, Medical Orders for Scope of Treatment). A 2019 systematic review7 identified 34 unique interventions to guide advance care planning. Notably, only 1 of the interventions included a video, which was used alongside group sessions to discuss overall care plans. Having videos that focus only on CPR (which can appear brutal) might perpetuate the idea that CPR needs to be considered in isolation from other treatments or treatment goals. A video—which is inherently generic—might also detract from the need to individualize the conversation; ideally, discussions should enable the clinician and patient to achieve a shared understanding of what outcomes that particular patient values and what outcomes are clinically achievable for them.6 Randomized clinical trials require uniformity and consistency of intervention, and a video lends itself to this kind of rigorous evaluation. However, trying to achieve improvements in the way overall decisions are made and recorded may require more nuanced, mixed-methods evaluation. In supporting the call from Becker et al2 for large randomized clinical trials to investigate the best approaches to facilitate DNR decisions, perhaps future research should focus on the optimal approach to overall treatment plans, rather than DNR in isolation.

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Article Information

Published: June 7, 2019. doi:10.1001/jamanetworkopen.2019.5170

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Perkins GD et al. JAMA Network Open.

Corresponding Author: Gavin D. Perkins, MD, FRCP, FFICM, Warwick Clinical Trials Unit, Warwick Medical School, Coventry, Warwick CV4 7AL, United Kingdom (g.d.perkins@warwick.ac.uk).

Conflict of Interest Disclosures: Drs Perkins and Fritz reported receiving grants from the National Institute for Health Research (NIHR) Health Service Delivery Research Programme (reference 12/5001/55 and 15/15/09). Dr Perkins reported receiving support from the Invensive Care Foundation and serving on the Resuscitation Council (UK) Executive Committee and ReSPECT working group. Dr Fritz reported receiving grant 208213/Z/17/Z from Wellcome Trust; serving on the executive committee of Resuscitation Council (UK); and chairing the subcommittee for the Recommended Summary Plan for Emergency Care and Treatment.

Disclaimer: The views expressed are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

References
1.
Bossaert  LL, Perkins  GD, Askitopoulou  H,  et al; Ethics of Resuscitation and End-of-Life Decisions Section Collaborators.  European Resuscitation Council Guidelines for Resuscitation 2015: section 11: the ethics of resuscitation and end-of-life decisions.  Resuscitation. 2015;95:302-311. doi:10.1016/j.resuscitation.2015.07.033PubMedGoogle ScholarCrossref
2.
Becker  C, Lecheler  L, Hochstrasser  S,  et al.  Association of communication interventions to discuss code status with patient decisions for do-not-resuscitate orders: a systematic review and meta-analysis.  JAMA Netw Open. 2019;2(6):e195033. doi:10.1001/jamanetworkopen.2019.5033Google Scholar
3.
Perkins  GD, Griffiths  F, Slowther  AM,  et al.  Do-Not-Attempt-Cardiopulmonary-Resuscitation Decisions: An Evidence Synthesis. Southampton, United Kingdom: NIHR Journals Library; 2016.
4.
Mockford  C, Fritz  Z, George  R,  et al.  Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation.  Resuscitation. 2015;88:99-113. doi:10.1016/j.resuscitation.2014.11.016PubMedGoogle ScholarCrossref
5.
Field  RA, Fritz  Z, Baker  A, Grove  A, Perkins  GD.  Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions.  Resuscitation. 2014;85(11):1418-1431. doi:10.1016/j.resuscitation.2014.08.024PubMedGoogle ScholarCrossref
6.
Fritz  Z, Slowther  AM, Perkins  GD.  Resuscitation policy should focus on the patient, not the decision.  BMJ. 2017;356:j813. doi:10.1136/bmj.j813PubMedGoogle ScholarCrossref
7.
Fahner  JC, Beunders  AJM, van der Heide  A,  et al.  Interventions guiding advance care planning conversations: a systematic review.  J Am Med Dir Assoc. 2019;20(3):227-248. doi:10.1016/j.jamda.2018.09.014PubMedGoogle ScholarCrossref
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