Evidence-base: DNACPR and EoLC decision making is challenging. The recent NCEPOD report (Time to Intervene, 2012) has highlighted the need to make such decisions as regularly and early as possible. A previous audit at our institution (Harkness et al; Q J Med 2006;99:683-690) demonstrated significant improvement was required in the consistency and number of CPR decisions being made.
Change strategies: A revised DNACPR form, decision making tools, and updated CPR guidelines have since been introduced. A prospective case note audit on Elderly and Acute medical inpatients was carried out over four days. This assessed CPR decision making, ceiling of care, EoLC preferences and patient capacity against best practice, then compared results to the audit performed in 2006.
Change effects: There was no improvement since 2006. In the 210 patients included, only 76 (36%) CPR decisions were made, of which 96.1% were DNACPR. Of these patients, 40.2% of the patients in
Elderly Medicine compared to 8.3% in Acute Medicine had a CPR decision made. Only 9 cases had a ceiling of care documented, all of which were within Elderly Medicine. 17 decisions were made <24 hours of admission but 30 were made after 7 days. In only 61% of cases was a DNACPR decision discussed with either the patient or next of kin. Capacity was documented in 18 cases and end of life preferences in 15 cases.
Conclusions: Geriatricians were more likely than Acute Physicians to make CPR and EoLC decisions. The lack of improvement in CPR decision making, despite a clear policy and pathway, suggests a novel approach to this issue is required.
We are currently piloting a mandatory Consultant-led Post Take Ward Round checklist to include CPR decision-making and Ceiling of Care. This has been piloted on the stroke wards, the results of which are being reported separately.