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

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.