ICS SOA 2015

1. Rethinking DNACPR orders:
ethical issues
and a proposal for change
Dr. Zoë Fritz
Wellcome Fellow in Bioethics
Consultant Physician, Acute Medicine

2. Current use In Hospitals
• 80% of those who die in hospital die with one in
place
• Majority initiated by clinicians
• 50% of patients with DNACPR in hospital are
discharged home.
• In the front of notes, often red – problems exist
with current approach
Fritz ZB et al. Characteristics and outcome of patients with DNACPR orders in an acute hospital; an
observational study. Resuscitation 85 (2014) 104–108

3. Q1: How often do you go to assess a
patient
(excluding post arrest patients)
who has been referred to ICU and think
they should have a DNACPR order?
A. Never
B. Once a shift
C. Once a week on the unit
D. Once a year
E. Once in a blue moon Never
Once
a
shift
Once
a
w
eekon
the
unit
Once
a
year
Once
in
a
blue
m
oon
1%
43%
1%2%
53%

4. Issue 1 : Not routinely completed
• Qualitative study Cohn et al Q J Med 2013; 106:165–177
• Completed on an ad hoc basis
• NCEPOD report
• 430/522 (78%) of patients had no resuscitation status decision
documented
• 7/573 patients who underwent CPR were on an end of life care
pathway

5. Ethical implication:
• ‘Lottery’ of whether resuscitation decision
gets considered

8. Q2: How often have you gone to a patient
who has survived an attempted
resuscitation attempt, and not admitted
them to ICU because you don’t think they
would benefit.
A. Never
B. Once a shift
C. Once a week on the unit
D. Once a year
E. Once in a blue moon Never
Once
a
shift
Once
a
w
eekon
the
unit
Once
a
year
Once
in
a
blue
m
oon
1%
8%
4%
35%
52%

9. Issue 2 : Inappropriate resuscitation
attempts
• NCEPOD: 118/202
patients who had survived
resuscitation were not
admitted to ICU

10. Ethical implication:
• Receiving unwanted treatments at the end
of life
• Perceived ‘undignified’ death
• Resources being used to no (or negative)
effect

11. Q3: How often do you wish a nice, calm conversation
had been had with a patient and their family in advance
about what they would and wouldn’t want in the event
of their deterioration, and it was all beautifully
documented?
A. Never
B. Once a shift
C. Once a week on the unit
D. Once a year
E. Once in a blue moon
Never
Once
a
shift
Once
a
w
eekon
the
unit
Once
a
year
Once
in
a
blue
m
oon
2%
59%
2%4%
33%

12. Issue 3: No one likes discussing this
• Patients rarely initiate discussions, doctors don’t like to
have discussions
• In 2012 50% discussed with patients or relatives
Fritz ZB et al. Characteristics and outcome of patients with DNACPR orders in an acute hospital; an
observational study. Resuscitation 85 (2014) 104–108
• Recent judgments have made in illegal not to discuss a
decision to withhold CPR…

13. Tracey
• Must discuss unless you think it would cause physiological
or psychological harm – to not do so would be in breach of
article 8 of Human Rights Act
• If you don’t tell a patient that you have made a decision,
you are depriving them of the right to question it, and the
right to ask for a second opinion
• This extends to other treatments as well
• Other areas of non disclosure to be challenged?
• R(Tracey) v Cambridge University Hospital NHS FT and others [2014] EWCA Civ 822 )

14. Winspear
• If a patient does not have capacity:
• Don’t make a ‘holding decision’ and wait ‘til the morning
• As long as it is ‘practicable and appropriate’ call someone who
knows them
Winspear v City Hospitals Sunderland NHS FT
[2015] EWHC 3250 (QB)

15. Burke still stands
• The patient still does not have the right to
demand a clinical treatment that is not
considered in their interests
• They do have a right
• to know that that a decision has been made and
• to question it

16. Ethical implications..
• Focus has been on patients having DNACPR ‘without
knowledge’ and the issues associated with this –
autonomy, right to private life, etc
• Some patients anxious about being resuscitated; not
talking with them about DNACPR may cause as much
more distress
(in preparation, A Malyon)

17. Issue 4: Misunderstood
• Less frequently referred to outreach or receive out of
hours care
Interpretation and intent: A study of the (mis)understanding of DNAR orders in
a teaching hospital Z Fritz et al Resuscitation 2010 81;9: 1138-1141
• Reduction in the urgency attached to reviewing a
deteriorating patient.
The over-interpretation of DNAR Stewart, M. et al Clin Gov 2011 16;2:119-128
• Most common reason for no DNACPR in NCEPOD “Full
and active management” 76.9%

18. Issue 5: Difference in care
• Chen – reduction in treatment for heart failure
Chen JL, et al (2008) Impact of do-not resuscitate orders on quality of care performance
measures in patients hospitalized with acute heart failure. Am Heart J 156: 78–84.
• Cohen – best predictor of not being admitted to
ICU
Cohen RI, et al(2009) The impact of donot-resuscitate order on triage decisions to a
medical intensive care unit. J Crit Care 24: 311–5.
• Kazaure – increased mortality in surgical patients
Kazaure H, et al (2011) High mortality in surgical patients with
do-not-resuscitate orders: analysis of 8256 patients. Arch Surg 146: 922–8.
• Beach and Henneman – scenario experiments
Henneman EA et al(1994) Effect of do not-resuscitate orders on the nursing care of
critically ill patients. Am J Crit Care 3: 467–72.
Beach MC et al (2002) The effect of do-not-resuscitate orders on physician decision-
making. J Am Geriatr Soc 50: 2057–61.

19. Ethical Implication…
• Discrimination, lack of equity
..and feeds into all of the above:
• Reluctance to write them
• Reluctance to talk about them
• How much information you give a patient

20. We tried to address the ethical
problems we saw in current
DNACPR practice in hospitals.

21. Aims of an alternative approach
• Remove the ad hoc nature of consideration
• Improve discussions
• Improve care for those in whom a decision not to
resuscitate had been made
• Remove ‘resus’ labeling
• Shift dichotomy to goals of care
• Encourage forward thinking
• Provide instruction if a patient deteriorates
• Maintain clarity about resuscitation

22. Universal Form of Treatment Options
(UFTO) development
• Designed iteratively using adapted delphi method
• Focus groups, interviews, questionnaires, feedback
• with
• Patients
• Nurses
• Doctors
• Resuscitation officers
• Behavioural economist

24. Assessment of UFTO
• Before and after study
• Contemporaneous case controls
• One hospital, Non-randomised, but outcomes were
blinded…
• Fritz Z, et al. (2013) The Universal Form of Treatment Options (UFTO) as an
Alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Orders: A
Mixed Methods Evaluation of the Effects on Clinical Practice and Patient Care. PLoS
ONE 8(9): e70977. doi:10.1371/journal.pone.0070977
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0070977

25. GlobalTriggerToolAnalysison thosepatientsin whoma
decisionnotto attemptresuscitationwasmade
DNAR period
(May-July 2010)
n = 103
UFTO period
(Nov 2010-Jan ‘11)
n = 118
Between group
difference
(95% CI)
P-value§
Harm rate
per 100 admissions
68.9 37.3
31.6
(12.2 to 51.1)
0.001
Harm rate
per 1000 patient days
34.7 21.8
12.9
(2.6 - 23.2)
0.01
Harms contributing to patient
death
(categories H and I)
23/71 (32%) 4/44 (9.1%)
23.3%
(7.8% to 36.1%)
0.006
Harms preventable on any level
(categories 2-4)
66/71 (93%) 43/44 (98%)
-4.8%
(-13.4% to 5.6%) 0.40
§P-value calculated using Fisher’s Exact test for categorical variables, and a z-test for rates

26. Summary of UFTO changes
• Change in culture
• Change in reasoning and nature of discussions
• Earlier recognition of palliative care needs
• Reduction in objective harms occurring to those who were
not for attempted resuscitation

27. Other national and international work
• Treatment Escalation Plan in Devon – M. Mercer et al
• ‘Deciding Right’ in the North East – C. Regnard et al
• ‘Unwell Patient’ S. Guglani, D Gabbot
• ‘Collaborative Child and Young Person’s Advance Care
Plan Group.’
• ‘Physician Orders for Life Sustaining treatment’ in the US
• Review of current practice and problems – systematic
review and other work - G. Perkins et al

28. Emergency Care and Treatment Plan
• Co-Chaired by the Resus council and the RCN
• Stakeholders from all clinical specialties, paramedics,and
patient and public groups
• Iterative process
• Using available evidence

29. The following treatment plan should be used as clinical guidance and is not a substitute for ongoing
consultation and shared decision-making wherever possible. The clinician should initial ONE of the
patient’s priority boxes below, add relevant guidance in the large box and initial a CPR decision.
The form must be signed, named and dated on the reverse.
Name:
Date of Birth: Hospital/NHS numbers:
Address:
1
This individual is FOR attempted
CARDIOPULMONARY RESUSCITATION
Signature…………………………………… 6
This individual is NOT FOR attempted
CARDIOPULMONARY RESUSCITATION
Signature……………………………………
If the patient dies in transit please take to: 6
Please provide clinical guidance on specific interventions that may or may not be wanted or
clinically appropriate in community, hospital and critical care settings:
Provide details of other relevant care planning documents and/or documented wishes about
organ/tissue donation (name and where held):
5
The priority is to get better.
Please consider all treatment
to prolong life
Initials: ..……………………. 4
The priority is to achieve a
balance between getting
better and ensuring good
quality of life. Please consider
selected treatments
Initials: ..…………………… 4
The priority is comfort. Please
consider all treatments aimed
at symptom control
Initials: ..…………………… 4
Turn%over%to%complete%this%ECTP%
Relevant information about the individual’s diagnosis, situation, ability to communicate, and reasons for the
chosen plan.
3
Emergency Care &
Treatment Plan
!
3!
Date: __/__/____
2

30. Designation -
(Grade and specialty)
Print name & professional
registration number
Signature Date and time
Senior Responsible Clinician 10
Plan review: If the individual’s condition changes (i.e. deterioration OR improvement) review the decisions
on this ECTP. Document further conversations in box 8. If necessary, complete a new form, and write
“CANCELLED” clearly across both sides of this form with signature and date. The decisions on this form
should be reviewed specifically before any procedure during which abrupt deterioration or cardiac arrest
may occur (e.g. endoscopy, cardiac pacing, angiography, surgery or anaesthesia). Make an agreed plan on
whether or not to revoke temporarily the decisions on this form and, if so, on the treatments that will be
considered if abrupt deterioration or cardiac arrest occurs. 11
Emergency contacts Name Telephone numbers Other relevant details
Welfare Attorney, Guardian etc
Family/friend
GP
Lead Consultant
Specialist worker/key worker 12
Does the (adult) individual
have capacity?
(see guidance notes)
7
Yes
No
Do they have a valid advance directive or ADRT?
If so, record details in box 5 7
Do they have a representative with legal authority to make decisions (e.g. Welfare
Attorney, Guardian, person with a Lasting Power of Attorney for Health and Welfare)?
If so, contact them and document details of discussion below 7
These decisions: 1. have been discussed with and agreed with the individual;
or 2. have been made in accordance with capacity law;
or 3. in the case of a child, the person holding parental responsibility/court order.
Date of discussion: __/__/____ Names of those present:
Full documentation of discussion can be found in:
Further conversations occurred on the following dates (state where details are recorded):
8
If there has been no shared decision-making with the individual, no shared decision-making with a
representative with legal authority to make decisions or no best-interests meeting for the individual who
lacks capacity, document a full explanation and a clear plan to address this in the clinical records.
Summarise the reason (e.g. describe any potential to cause harm) here:
9

31. Almost ready for…
• Public consultation
• Usability testing
• Multi-Centre Evaluation

32. ‘Take home messages’
• Do Not Attempt Resuscitation Decisions associated with
problems in initiating, discussing and documenting
decisions, and can have unintended effects
• A new approach, contextualising the resuscitation
decision within overall goals of care has been developed
• Get involved with the consulatative process – may be
coming to a hospital near you soon!

33. Thank you
Patients and staff
NIHR, Wellcome trust
Colleagues in Cambridge and Warwick, the
Reususcitation Council, and all of those working
on the Emergency Care and Treatment Plan
Zoefritz@gmail.com
www.ufto.org