Resuscitation policy should focus on the patient, not the decision

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Abstract

Zoë Fritz and colleagues discuss new approaches to resuscitation decisions that incorporate broader goals of care

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Toward Evidence-Based End-of-Life Care.

Scott D Halpern (2015)

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Prospective study of health status preferences and changes in preferences over time in older adults.

V Towle, John J. O’Leary, William T Gallo … (2006)

Instructional forms of advance care planning depend on the ability of patients to predict their future treatment preferences. However, preferences may change with changes in patients' health states. We conducted in-home interviews of 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease at least every 4 months for up to 2 years. Patients were asked to rate whether treatment for their illness would be acceptable if it resulted in 1 of 4 health states. The likelihood of rating as acceptable a treatment resulting in mild (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.06-1.16) or severe (OR, 1.06; 95% CI, 1.03-1.09) functional disability increased with each month of participation. Patients who experienced a decline in their ability to perform instrumental activities of daily living were more likely to rate as acceptable treatment resulting in mild (OR, 1.23; 95% CI, 1.08-1.40) or severe (OR, 1.23; 95% CI, 1.11-1.37) disability. Although the overall likelihood of rating treatment resulting in a state of pain as acceptable did not change over time (OR, 0.98; 95% CI, 0.96-1.01), patients who had moderate to severe pain were more likely to rate this treatment as acceptable (OR, 2.55; 95% CI, 1.56-4.19) than were those who did not have moderate to severe pain. For some patients, the acceptability of treatment resulting in certain diminished states of health increases with time, and increased acceptability is more likely among patients experiencing a decline in that same domain. These changes pose a challenge to advance care planning, which asks patients to predict their future treatment preferences.

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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

Zoë Fritz, Alexandra Malyon, Jude Frankau … (2013)

Aims To determine whether the introduction of the Universal Form of Treatment Options (the UFTO), as an alternative approach to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, reduces harms in patients in whom a decision not to attempt cardiopulmonary resuscitation (CPR) was made, and to understand the mechanism for any observed change. Methods A mixed-methods before-and-after study with contemporaneous case controls was conducted in an acute hospital. We examined DNACPR (103 patients with DNACPR orders in 530 admissions) and UFTO (118 decisions not to attempt resuscitation in 560 admissions) practice. The Global Trigger Tool was used to quantify harms. Qualitative interviews and observations were used to understand mechanisms and effects. Results Rate of harms in patients for whom there was a documented decision not to attempt CPR was reduced: Rate difference per 1000 patient-days was 12.9 (95% CI: 2.6–23.2, p-value = 0.01). There was a difference in the proportion of harms contributing to patient death in the two periods (23/71 in the DNACPR period to 4/44 in the UFTO period (95% CI 7.8–36.1, p-value = 0.006). Significant differences were maintained after adjustment for known confounders. No significant change was seen on contemporaneous case control wards. Interviews with clinicians and observation of ward practice revealed the UFTO helped provide clarity of goals of care and reduced negative associations with resuscitation decisions. Conclusions Introducing the UFTO was associated with a significant reduction in harmful events in patients in whom a decision not to attempt CPR had been made. Coupled with supportive qualitative evidence, this indicates the UFTO improved care for this vulnerable group. Trial Registration Controlled-Trials.com ISRCTN85474986 UK Comprehensive Research Network Portfolio 7932

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Author and article information

Contributors

Zoë Fritz: Role: Wellcome fellow in society and ethics and consultant in acute medicine

Anne-Marie Slowther: Role: reader in clinical ethics

Gavin D Perkins: Role: professor of critical care medicine

Journal

Journal ID (nlm-ta): BMJ

Journal ID (iso-abbrev): BMJ

Journal ID (publisher-id): bmj

Title: The BMJ

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1756-1833

Publication date Collection: 2017

Publication date (Electronic): 28 February 2017

Volume: 356

Electronic Location Identifier: j813

Affiliations

[1 ]Warwick Medical School, Division of Health Sciences, Gibbet Hill Campus, Coventry CV4 7AL, UK

[2 ]Cambridge University Hospitals

[3 ]Heart of England NHS Foundation Trust, University of Warwick

Author notes

Correspondence to: zoe.fritz@ 123456addenbrookes.nhs.uk

Accepted 13 February 2017

Article

Publisher ID: friz037948

DOI: 10.1136/bmj.j813

PMC ID: 5330195

PubMed ID: 28246084

SO-VID: 6e90199e-5ef9-48b6-bcb1-712388e3a2fd

License:

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

Resuscitation policy should focus on the patient, not the decision

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Most cited references 16

Toward Evidence-Based End-of-Life Care.

Prospective study of health status preferences and changes in preferences over time in older adults.

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

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