Doctors’ experiences of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision making: A meta-ethnography

Aims: The aim of this study is to use meta-ethnography to analyse and synthesise qualitative data that considers doctors experiences and attitudes towards DNACPR decision making.Background: DNACPR decisions identify patients who would not benefit from having cardiopulmonary resuscitation attempted. With recent high profile media interest and published recommendations1 there is a need for a greater understanding about doctors’ attitudes towards DNACPR decisions, and the barriers which they perceive when making such decisions.Methods: A comprehensive literature search was conducted including MEDLINE, EMBASE, PsychINFO, CINAHL, Cochrane library, PubMed, Web of Science and bibliographical reviews of retrieved studies (February 2002–2013). All retrieved articles were reviewed to identify published qualitative research focusing on doctor's experience/attitudes of DNACPR decision making in Adults. The original search identified 377 studies. After exclusions nine relevant studies were identified. Two researchers independently reviewed and critically appraised the studies. Key themes and concepts were extracted from each study. Techniques of meta-ethnography were followed to synthesise the findings.Result: Four major themes were identified that highlight common issues and concerns experienced by doctors: ethical concerns, decision making, conflicts and communication. A line of argument synthesis produced a decision-dilemma model that describes the challenges faced in three distinct phases of DNACPR decision making: pre decision, making the decision and post decision.Conclusions: Doctors experience a range of common concerns and issues which may affect the decision making process. DNACPR decisions are influenced by balancing conflicting clinical and ethical demands. This information is well placed to inform future training and policy to provide support for doctors when making DNACPR decisions

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

Systematic review of interventions to improve outcomes associated with do-not-attempt-resuscitation orders

Despite being in existence for over 30 years,1 the implementation and recording of do not attempt resuscitation (DNAR) orders is often poor.2 Orders are often not issued when required and patient involvement in decision making is sub-optimal.2 This review set out to identify interventions to improve implementation of in-hospital adult DNAR orders

Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions

AbstractBackgroundThe treatment for a cardiac arrest, cardiopulmonary resuscitation (CPR), may be lifesaving following an acute, potentially reversible illness. Yet this treatment is unlikely to be effective if cardiac arrest occurs as part of the dying process towards the end of a person's natural life. Do not attempt CPR (DNACPR) decisions allow resuscitation to be withheld when it has little chance of success, or where the patient, or those close to the patient, indicate the burdens of CPR outweigh the benefits. This review sought to identify evidence for systems that improve the appropriate use of DNACPR decisions.MethodsElectronic databases were searched (Medline, CINAHL and Embase) for English language articles from 2001 to 2014.Results4090 citations were identified of which 37 studies were relevant. The overall quality of evidence was moderate to poor. Thematic synthesis identified key interventions which may improve DNACPR decision making. The most promising interventions involved structured discussion at the time of acute admission to hospital and review by specialist teams at the point of an acute deterioration. Linking DNACPR decisions to discussions about overall treatment plans provided greater clarity about goals of care, aided communication between clinicians and reduced harms. Standardised documentation proved helpful for improving the frequency and quality of recording DNACPR decisions. Patient and clinician education in isolation were associated with limited or no effects.ConclusionRelatively simple process changes may enhance the appropriate use of and outcomes associated with DNACPR decisions.Systematic review registration number: PROSPERO2012:CRD42012002669

A simple solution for improving reliability of cardiac arrest equipment provision in hospital.

INTRODUCTION Effective and safe cardiac arrest care in the hospital setting is reliant on the immediate availability of emergency equipment. The patient safety literature highlights deficiencies in current approaches to resuscitation equipment provision, highlighting the need for innovative solutions to this problem. METHODS We conducted a before-after study at a large NHS trust to evaluate the effect of a sealed tray system and database on resuscitation equipment provision. The system was evaluated by a series of unannounced inspections to assess resuscitation trolley compliance with local policy prior to and following system implementation. The time taken to check trolleys was assessed by timing clinicians checking both types of trolley in a simulation setting. RESULTS The sealed tray system was implemented in 2010, and led to a significant increase in the number of resuscitation trolleys without missing, surplus, or expired items (2009: n=1 (4.76%) vs 2011: n=37 (100%), p<0.001). It also significantly reduced the time required to check each resuscitation trolley in the simulation setting (12.86 (95% CI: 10.02-15.71) vs 3.15 (95% CI: 1.19-4.51)min, p<0.001), but had no effect on the number of resuscitation trolleys checked every day over the previous month (2009: n=8 (38.10%) vs 2011: n=11 (29.73%), p=0.514). CONCLUSION The implementation of a sealed tray system led to a significant and sustained improvement in resuscitation equipment provision, but had no effect on resuscitation trolley checking frequency