How might a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision affect other aspects of patient care?

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YuenKang Tham1; Dafydd Brooks1; Ashwin Venkatesh1; Antony Johansen1.
1. University Hospital of Wales and College of Medicine, Cardiff University
Scientific Research
SP - Ethics and Law
Treatment escalation plans
View DOI

Abstract

Introduction
Clinicians are regularly encouraged to make discussion and documentation of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status a routine part of their assessment and care of older patients. However, patients, their families and clinicians often question whether a DNACPR decision may affect the attention paid to other aspects of patient care, or their access to interventions unrelated to CPR. We set out to directly test and address this question using a randomised controlled study of a clinical vignette.

Methods
We presented a clinical scenario of a deteriorating patient to 226 senior geriatricians and specialist trainees. Using a double-blind approach, different geriatricians received alternative versions of the scenario which differed only in whether a DNACPR decision was in place. Geriatricians' subsequent management choices were compared between the two groups.

Results
In responding to a series of questions about escalation of care, the 110 respondents (48.7%) took significantly different approaches to the two versions of the scenario. In the presence of a DNACPR status, significantly fewer geriatricians considered naloxone in the context of potential opioid toxicity (32.7% vs. 58.2%; p<0.01). Similarly, fewer geriatricians considered non-invasive ventilation for Type 2 Respiratory failure (67.3% vs. 83.6%; p<0.05) or referral for intensive care (10.9% vs. 25.5%; p<0.05) in the presence of a DNACPR status.

Conclusions
This study demonstrates that clinicians should be aware that a patient's DNACPR status can lead to unconscious bias when other decisions are made, especially in busy acute settings. These findings should inform how we respond to case presentations and train resident doctors, highlighting the need for more sophisticated approaches to treatment escalation plans so these capture the nuances of discussion of patients' priorities rather than just DNACPR status documentation.

Presentation

Comments

This poster is very insightful! I hope all clinicians will take this learning into clinical practice and avoid bias associated with DNACPR status.

Submitted by georgia.paddin… on

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This is very interesting particularly regarding decisions around naloxone and NIV as we often reassure patients they would still be for all treatment to prevent cardiac arrest. Is there any breakdown by Seniority? It would be interesting to know if Consultants are more of less likely to escalate compared to the Specialty Trainees. 

Submitted by natashalander_21519 on

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Great question. All Specialty Trainees reported they would be likely to consider NIV in the absence of a DNACPR compared to 75.7% of the consultants in the group with a p=0.02 as reported as part of our paper.

Submitted by yuenkang.tham_32757 on

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Very interesting study and something to reflect on in our own practice. Do you plan to develop any interventions based on this to tackle the bias identified?

Submitted by lucy.miller47@… on

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Thanks Lucy. It will have to be a multifaceted approach through awareness of such, education, training and ground interventions like the ResPECT document (or alternatively the UFTO) which provide a more holistic framework of patient wishes and direction of treatment

This is a very interesting study that tackle an important clinical question. I agree that having DNACPR shouldn't affect patient care in any way. The conclusion's point about unconscious bias is interesting. I believe further studies comparing the effect of DNACPR on patient related outcomes is necessary in this context. 

Submitted by moh.mort89_47757 on

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A really interesting piece of evaluation and should make clinicians reflect on our potential unconscious bias when treating reversible causes in patients with a DNACPR decision. 

Submitted by catrin.hughes@… on

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Really important findings, and a well-designed study!

Have you explored whether seniority or specialty training influenced susceptibility to this bias?

Submitted by emilywei1999_47816 on

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Great poster. Very interesting. Be interesting to know if other specialists might show similar results. Have you thought about asking intensivists or surgeons similar scenarios (for example, would they be less likely to admit to ITU or take to theatre if they had a DNACPR form in place)?

Submitted by gareth.davies2… on

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It may be interesting to explore those. However, this study is likely to suffice as food for reflection by our colleagues of other specialties.

This is a really interesting study! It would be interesting to see whether this effect occurs in other specialties also, and whether the prevalance of this effect was different amongst our colleagues outside of geriatric medicine. 

Submitted by catherine.grib… on

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Very interesting and insightful study. Reinforced the need for clinicians to clearly document the discussions relating to DNACPR vs ceilings of care as separate issues to avoid biases and ensure patients wishes are respected 

Submitted by kepowell97_31417 on

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