Peri-operative cardiac arrest in the older frail patient as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

Frailty increases peri-operative risk, but details of its burden, clinical features and the risk of, and outcomes following, peri-operative cardiac arrest are lacking. As a preplanned analysis of the 7th National Audit Project of the Royal College of Anaesthetists, we described the characteristics of older patients living with frailty undergoing anaesthesia and surgery, and those reported to the peri-operative cardiac arrest case registry. In the activity survey, 1676 (26%) of 6466 patients aged > 65 y were reported as frail (Clinical Frailty Scale score ≥ 5). Increasing age and frailty were both associated with increasing comorbidities and the proportion of surgery undertaken as an emergency. Except in patients who were terminally ill (Clinical Frailty Scale score 9), increasing frailty was associated with an increased proportion of complex or major surgery. The rate of use of invasive arterial blood pressure monitoring was associated with frailty only until Clinical Frailty Scale score 5, and then plateaued or fell. Of 881 cardiac arrests reported to the 7th National Audit Project, 156 (18%) were in patients aged > 65 y and living with frailty, with an estimated incidence of 1 in 1204 (95%CI 1 in 1027-1412) and a mortality rate of 1 in 2020 (95%CI 1 in 1642-2488), approximately 2.6-fold higher than in adults who were not frail. Hip fracture, emergency laparotomy, emergency vascular surgery and urological surgery were the most common surgical procedures in older patients living with frailty who had a cardiac arrest. We report a high burden of frailty within the surgical population, requiring complex, urgent surgery, and the extent of poorer outcomes of peri-operative cardiac arrest compared with patients of the same age not living with frailty.

Resuscitation (un-)wanted: Does anyone care? A retrospective real data analysis.

BACKGROUND AND OBJECTIVES: In case of out-of-hospital cardiac arrest (OHCA) personnel of the emergency medical services (EMS) are regularly confronted with advanced directives (AD) and do-not-attempt-resuscitation (DNACPR) orders. The authors conducted a retrospective analysis of EMS operation protocols to examine the prevalence of DNACPR in case of OHCA and the influence of a presented DNACPR on CPR-duration, performed Advanced-Life-Support (ALS) measures and decision making. MATERIALS AND METHODS: Retrospective analysis of prehospital medical documentation of all resuscitation incidents in a German county with 250,000 inhabitants from 1 January 2016 to 31 December 2022. Combined with data from the structured CPR team-feedback database patients characteristics, measures and course of the CPR were analysed. Statistic testing with significance level p < 0.05. RESULTS: In total n = 1,474 CPR events were analysed. Patients with DNACPR vs. no DNACPR: n = 263 (17.8%) vs. n = 1,211 (82.2%). Age: 80.0 ± 10.3 years vs. 68.0 ± 13.9 years; p < 0.001. Patients with ASA-status III/IV: n = 214 (81.3%) vs. n = 616 (50.9%); p < 0.001. Initial layperson-CPR: n = 148 (56.3%) vs. n = 647 (55.7%); p = 0.40. Airway management: n = 185 (70.3%) vs. n = 1,069 (88.3%); p < 0.001. With DNACPR CPR-duration initiated layperson-CPR vs. no layperson-CPR: 19:14 min (10:43-25:55 min) vs. 12:40 min (06:35-20:03 min); p < 0.001. CONCLUSION: In case of CPR EMS-personnel are often confronted with DNACPR-orders. Patients are older and have more previous diseases than patients without DNACPR. Initiated layperson-CPR might lead to misinterpretation of patients will with impact on CPR-duration and unwanted measures. Awareness of this issue should be created through measures such as training programs in particular to train staff in the interpretation and legal admissibility of ADs.

Peri-operative decisions about cardiopulmonary resuscitation among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

Current guidance recommends that, in most circumstances, cardiopulmonary resuscitation should be attempted when cardiac arrest occurs during anaesthesia, and when a patient has a pre-existing 'do not attempt cardiopulmonary resuscitation' recommendation, this should be suspended. How this guidance is translated into everyday clinical practice in the UK is currently unknown. Here, as part of the 7th National Audit Project of the Royal College of Anaesthetists, we have: assessed the rates of pre-operative 'do not attempt cardiopulmonary resuscitation' recommendations via an activity survey of all cases undertaken by anaesthetists over four days in each participating site; and analysed our one-year case registry of peri-operative cardiac arrests to understand the rates of cardiac arrest in patients who had 'do not attempt cardiopulmonary resuscitation' decisions pre-operatively. In the activity survey, among 20,717 adults (aged > 18 y) undergoing surgery, 595 (3%) had a 'do not attempt cardiopulmonary resuscitation' recommendation pre-operatively, of which less than a third (175, 29%) were suspended. Of the 881 peri-operative cardiac arrest reports, 54 (6%) patients had a 'do not attempt cardiopulmonary resuscitation' recommendation made pre-operatively and of these 38 (70%) had a clinical frailty scale score ≥ 5. Just under half (25, 46%) of these 'do not attempt cardiopulmonary resuscitation' recommendations were formally suspended at the time of anaesthesia and surgery. One in five of these patients with a 'do not attempt cardiopulmonary resuscitation' recommendation who had a cardiac arrest survived to leave hospital and of the seven patients with documented modified Rankin Scale scores before and after cardiac arrest, four remained the same and three had worse scores. Very few patients who had a pre-existing 'do not attempt cardiopulmonary resuscitation' recommendation had a peri-operative cardiac arrest, and when cardiac arrest did occur, return of spontaneous circulation was achieved in 57%, although > 50% of these patients subsequently died before discharge from hospital.

Improving Completion Rates of Treatment Escalation Plan (TEP) in a London Teaching Hospital: A Quality Improvement Study.

Background Treatment escalation plans (TEPs) provide enhanced clarity in planning appropriate decision-making in the management of deteriorating patients by explicitly defining a limit of care. These decisions are discussed with patients or their relatives and mutually agreed upon. We aimed to improve staff adherence to the completion of TEPs upon the admission of patients to the orthopedics wards in a London teaching hospital. Methods This study employed the Plan-Do-Study-Act (PDSA) methodology to investigate the efficacy of interventions implemented within a hospital setting for adult inpatients receiving orthopedic treatment. The approach adopted was cross-sectional, where a comprehensive audit was conducted on all adult inpatients admitted to the hospital. The initial cycle of the study was conducted in March 2022, followed by the implementation of interventions in the form of an internal algorithm. Subsequently, the second cycle of the study was conducted in November 2022. Results We sampled a total of 50 patients (PDSA 1, n=27; PDSA 2, n=23). Following the implementation of a designated local TEP pathway, the proportion of patients with incomplete TEPs fell from 30.4% (n=7, PDSA Cycle 1) to 11.76% (n=2, PDSA Cycle 2). Conclusions The study has demonstrated that interventions such as institutional algorithms and departmental meetings can be useful in improving the adherence of staff to complete TEPs. Ongoing training and education can help overcome some of the barriers to TEP completion.

To withhold resuscitation - The Swedish system's rules and challenges.

The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision "Do-Not-Attempt-Cardio-Pulmonary-Resuscitation" (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6-13% of patients dying in Swedish hospitals. According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will. Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions. We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.

Advance Care Planning and Place of Death During the COVID-19 Pandemic: A Retrospective Analysis of Routinely Collected Data.

Increased advance care planning was endorsed at the start of the Coronavirus disease 2019 (COVID-19) pandemic with the aim of optimizing end-of-life care. This retrospective observational cohort study explores the impact of advanced care planning on place of death. 21,962 records from patients who died during the first year of the pandemic and who had an Electronic Palliative Care Coordination System record were included. 11,913 (54%) had a documented place of death. Of these 5,339 died at home and 2,378 died in hospital. 9,971 (45%) had both a documented place of death and a preferred place of death. Of these, 7,668 (77%) died in their preferred location. Documented elements of advance care planning, such as resuscitation status and ceiling of treatment decisions, were associated with an increased likelihood of dying in the preferred location, as were the number of times the record was viewed. During the COVID-19 pandemic, advanced care planning and the use of digital care coordination systems presented an opportunity for patients and healthcare staff to personalize care and influence end-of-life experiences.

'That's as hard a decision as you will ever have to make': the experiences of people who discussed Do Not Attempt Cardiopulmonary Resuscitation on behalf of a relative during the COVID-19 pandemic.

BACKGROUND: COVID-19 brought additional challenges to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision-making, which was already a contentious issue. In the UK, reports of poor DNACPR decision-making and communication emerged in 2020, including from the regulator, the Care Quality Commission. This paper explores the experiences of people who discussed DNACPR with a healthcare professional on behalf of a relative during the coronavirus pandemic, with the aim of identifying areas of good practice and what needs to be improved. METHODS: a total of 39 people participated in semi-structured interviews via video conferencing software or telephone. Data were evaluated using Framework Analysis. FINDINGS: results are presented around three main themes: understanding, communication and impact. Participants' understanding about DNACPR was important, as those with better understanding tended to reflect more positively on their discussions with clinicians. The role of relatives in the decision-making process was a frequent source of misunderstanding. Healthcare professionals' communication skills were important. Where discussions went well, relatives were given clear explanations and the opportunity to ask questions. However many relatives felt that conversations were rushed. DNACPR discussions can have a lasting impact-relatives reported them to be significant moments in care journeys. Many relatives perceived that they were asked to decide whether their relative should receive CPR and described enduring emotional consequences, including guilt. CONCLUSION: the pandemic has illuminated deficiencies in current practice around DNACPR discussion, which can have difficult to anticipate and lasting negative consequences for relatives. This research raises questions about the current approach to DNACPR decision-making.

The experiences of adult patients, families, and healthcare professionals of CPR decision-making conversations in the United Kingdom: A qualitative systematic review.

Aim: To conduct a qualitative systematic review on the experiences of patients, families, and healthcare professionals (HCPs) of CPR decision-making conversations in the United Kingdom (UK). Methods: The databases PubMed, Embase, Emcare, CINAHL, and PsycInfo were searched. Studies published from 1 January 2012 describing experiences of CPR decision-making conversations in the UK were included. Included studies were critically appraised using the CASP tool. Thematic synthesis was conducted. Results: From 684 papers identified, ten studies were included. Four key themes were identified:(i) Initiation of conversations - Key prompts for the discussion included clinical deterioration and poor prognosis. There are different perspectives about who should initiate conversations.(ii) Involvement of patients and families - HCPs were reluctant to involve patients who they thought would become distressed by the conversation, while patients varied in their desire to be involved. Patients wanted family support while HCPs viewed families as potential sources of conflict.(iii) Influences on the content of conversations - Location, context, HCPs' attitudes and emotions, and uncertainty of prognosis influenced the content of conversations.(iv) Conversation outcomes - Range of outcomes included emotional distress, sense of relief and value, disagreements, and incomplete conversations. Conclusions: There is inconsistency in how these conversations occur, patients' desire to be involved, and between patients' and HCPs' views on the role of families in these conversations. CPR discussions raise ethical challenges for HCPs. HCPs need training and pastoral support in conducting CPR discussions. Patients and families need education on CPR recommendations and support after discussions.

Implementation of ReSPECT in acute hospitals: A retrospective observational study.

AIMS: To evaluate, in UK acute hospitals, the early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans. To understand for whom and how the process was being used and the quality of form completion. METHODS: A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes. RESULTS: The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement. CONCLUSIONS: ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement. STUDY REGISTRATION: https://www.isrctn.com/ISRCTN11112933.

DNACPR Decisions: Aligning Law, Guidance, and Practice.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions are a means to consider in advance the appropriateness of CPR measures if an acute crisis arises. During the COVID-19 pandemic, problems with such decisions, for example the putting in place of DNACPR decisions for all residents of certain care homes, received a lot of attention, prompting a Care Quality Commission (CQC) report with recommendations for improvement. Building on the CQC report, our article addresses a cluster of legal uncertainties surrounding DNACPR decisions, in particular about the grounds for such decisions and the correct procedures for the legally required consultation, including with whom to consult. This article will also analyse commonly used DNACPR forms, as well as the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, which aims to incorporate DNACPR decisions as part of more holistic end-of-life care planning. The analysis shows that all forms exhibit shortcomings in reflecting the legal requirements for DNACPR decisions. We recommend a number of changes to the forms aimed at rendering DNACPR practice compliant with the law and more protective of the person's human rights.

The Vicissitude of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Order During COVID-19 Pandemic in Japan - A Retrospective Cohort Study.

Introduction: Japan went through five surges of coronavirus disease 2019 (COVID-19) or "waves". However, their impacts on the do not attempt cardiopulmonary resuscitation (DNACPR) of the patients are not known. Methods: A retrospective single-center cohort study was conducted for all hospitalized patients with COVID-19 from March 1, 2020, to September 30, 2021. Their code status was retrieved, and its association with the waves and other parameters, such as in-hospital mortality, was investigated. The relationship between DNACPR status and each wave was examined, as well as the effect on in-hospital mortality. Results: A total of 1153 patients were hospitalized with the diagnosis of COVID-19 during the study period. On admission, 117 patients (10.1%) had DNACPR orders, 373 patients (32.4%) were on full code, 45 patients (3.9%) stated that they cannot decide code status. DNACPR rate appeared to increase at the summit of each wave. Subsequently, 160 patients (13.9%) became DNACPR status, 385 patients (33.4%) became full code, and 12 patients (1.0%) stated that they remained unable to decide code status. There was no association between DNACPR status and each wave, and DNACPR status was not associated with higher mortality (P = 0.87), both by logistic regression analysis. Conclusion: DNACPR status among hospitalized COVID-19 patients appeared to have changed over multiple waves in Japan, but it is more likely due to the change of the patients' demographics, particularly their age. DNACPR was common among the elderly, but it was not independently associated with higher mortality.

Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings.

BACKGROUND: We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). METHODS: A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. RESULTS: Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or 'not eligible for intensive care' (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. CONCLUSION: Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.

Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions in patients admitted through the emergency department in a Swedish University Hospital - An observational study of outcome, patient characteristics and changes in DNACPR decisions.

AIMS: The aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status. METHODS: This was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015. RESULTS: The cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration. CONCLUSION: For a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.

Comparison of clinicians' perceptions of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) before and during the COVID-19 pandemic.

INTRODUCTION: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process encourages collaboration between clinicians, patients, and relatives on emergency care wishes and resuscitation decisions. The impact of the COVID-19 pandemic on clinicians' views of the ReSPECT process was unknown. We examined whether there were changes in clinicians' knowledge, skills, and attitudes regarding ReSPECT during the pandemic. METHODS: We conducted a cross-sectional survey of clinicians at one acute hospital in the UK. We developed a questionnaire with a defined 5-point Likert scale and asked clinicians to recall their pre-pandemic views on ReSPECT and report their current views at the time of survey distribution (May 2020, end of the first COVID-19 wave in the UK). We compared their self-reported views before and during the pandemic. RESULTS: We analysed 171 questionnaire responses. Clinicians reported ReSPECT telephone discussions with relatives were more challenging (pre-pandemic median 4, IQR 3-4; during pandemic median 4, IQR 4-5; p < 0.001) and negative emotions whilst conducting these discussions with relatives increased during the pandemic (pre-pandemic median 3, IQR 2-3.5; during pandemic median 3, IQR 2-4; p < 0.001). Clinicians also reported an increase in the importance of reaching a shared understanding of decisions with patients and relatives (pre-pandemic median 4, IQR 4-5; during pandemic median 5, IQR 4-5; p < 0.001). CONCLUSIONS: There were differences in clinicians' knowledge, skills, and attitudes scores before and during the pandemic. Our findings highlighted that clinicians could benefit from training in remote ReSPECT conversations with relatives.

DNACPR decisions during Covid-19: An empirical and analytical study.

Considerable concern has arisen during the Covid pandemic over the use of Do Not Attempt Cardiopulmonary Resuscitation decisions (DNACPRs) in England and Wales, particularly around the potential blanket application of them on older adults and those with learning disabilities. In this article, we set out the legal background to DNACPRs in England and the concerns raised during Covid. We also report on an empirical study that examined the use of DNACPRs across 23 Trusts in England, which found overall increases in the number of patients with a DNACPR decision during the two main Covid 'waves' (23 March 2020-31 January 2021) compared with the previous year. We found that these increases were largest among those in mid-life age groups, despite older patients (in particular, older women) having a higher number of DNACPR decisions overall. However, further analysis revealed that DNACPR decisions remained fairly consistent with regard to patient sex and age, with small reductions seen in the oldest age groups. We found that a disproportionate number of Black Caribbean patients had a DNACPR decision. Overall, approximately one in five patients was not consulted about the DNACPR decision, but during the first Covid wave more patients were consulted than pre-Covid.

Pre-operative resuscitation discussion with patients undergoing fractured neck of femur repair: a service evaluation and discussion of current standards.

INTRODUCTION: The majority of neck of femur (NOF) fracture patients are frail and at a higher risk of cardiac arrest. This makes discussion of treatment escalation vital to informed care. The optimal time for these discussions is prior to admission or trauma. However, when this has not occurred, it is vital that these discussions happen early in the patient's admission when family is often present and before further deterioration in their condition. We undertook a service evaluation to evaluate and discuss the effect of clinician education on improving rates of timely discussion amongst orthopaedic doctors. MATERIALS AND METHODS: The first cycle included 94 patients. Their notes were reviewed for presence of a ReSPECT (Recommend Summary Plan for Emergency Care and Treatment) form prior to operation and whether this it countersigned by a consultant. Following this, clinician education was undertaken and a re-audit was carried out involving 57 patients. RESULTS: ReSPECT form completion rates rose from 23% in cycle 1-32% in cycle 2 following intervention. The proportion which consultants signed rose from 41% to 56% following intervention. CONCLUSION: This project demonstrates how a basic education program can prove limited improvements in the rates of timely resuscitation discussions. We discuss a current lack in quality research into educational programs for discussion of treatment escalation for orthopaedic trainees. We suggest there is room to improve national best practice guidelines and training to ensure these discussions are carried out more frequently and to a better standard.

Thinking ahead in advanced illness: Exploring clinicians' perspectives on discussing resuscitation with patients and families from ethnic minority communities.

BACKGROUND: Evidence suggests that discussing resuscitation with patients and relatives from ethnic minority groups is problematic for healthcare professionals (HCPs), but there is limited evidence exploring these issues or offering guidance for HCPs in navigating these challenging discussions. This study explores the barriers and enablers to HCPs discussing deterioration and resuscitation decisions with patients and families from ethnic minority groups. RESULTS: Personal, cultural, religious/spiritual and health beliefs, emotions, and communication quality and skills were discussed. Participants described that the interaction between these factors as complex, impacting the way some patients and families responded to do not attempt cardiopulmonary resuscitation (DNACPR) orders and the particular challenges these pose. CONCLUSION: Key barriers and enablers for healthcare professionals discussing resuscitation with patients and families from Black, Asian and minority ethnic communities were identified. The findings highlight areas of improvement for training, both relating to DNACPR discussions and 'cultural competence'.

Low adherence to legislation regarding Do-Not-Attempt-Cardiopulmonary-Resuscitation orders in a Swedish University Hospital.

BACKGROUND: The ethical principles of resuscitation have been incorporated into Swedish legislation so that a decision to not attempt cardiopulmonary resuscitation (DNACPR) entails (1) consultation with patient or relatives if consultation with patient was not possible and documentation of their attitudes; (2) consultation with other licensed caregivers; (3) documentation of the grounds for the DNACPR. Our aim was to evaluate adherence to this legislation, explore the grounds for the decision and the attitudes of patients and relatives towards DNACPR orders. METHODS: We included DNACPR forms issued after admission through the emergency department at Karolinska University Hospital between 1st January and 31st October, 2015. Quantitative analysis evaluated adherence to legislation and qualitative analysis of a random sample of 20% evaluated the grounds for the decision and the attitudes. RESULTS: The cohort consisted of 3583 DNACPR forms. In 40% of these it was impossible to consult the patient, and relatives were consulted in 46% of these cases. For competent patients, consultation occurred in 28% and the most common attitude was to wish to refrain from resuscitation. Relatives were consulted in 26% and they mainly agreed with the decision. Grounds for the DNAR decision was most commonly severe chronic comorbidity, malignancy or multimorbidity with or without an acute condition. All requirements of the legislation were fulfilled in 10% of the cases. CONCLUSION: In 90% of the cases physicians failed to fulfil all requirements in the Swedish legislation regarding DNAR orders. The decision was mostly based on chronic, severe comorbidity or multimorbidity.

General practitioners' experiences of emergency care and treatment planning in England: a focus group study.

BACKGROUND: Emergency Care and Treatment Plans are recommended for all primary care patients in the United Kingdom who are expected to experience deterioration of their health. The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was developed to integrate resuscitation decisions with discussions about wider goals of care. It summarises treatment recommendations discussed and agreed between patients and their clinicians for a future emergency situation and was designed to meet the needs of different care settings. Our aim is to explore GPs' experiences of using ReSPECT and how it transfers across the primary care and secondary care interface. METHODS: We conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. Participants were asked about their experience of ReSPECT, how they initiate ReSPECT-type conversations, and their experiences of ReSPECT-type recommendations being communicated across primary and secondary care. Focus groups were transcribed and analysed using Thematic Analysis. RESULTS: GPs conceptualise ReSPECT as an end of life planning document, which is best completed in primary care. As an end of life care document, completing ReSPECT is an emotional process and conversations are shaped by what a 'good death' is thought to be. ReSPECT recommendations are not always communicated or transferable across care settings. A focus on the patient's preferences around death, and GPs' lack of specialist knowledge, could be a barrier to completion of ReSPECT that is transferable to acute settings. CONCLUSION: Conceptualising ReSPECT as an end of life care document suggests a difference in how general practitioners understand ReSPECT from its designers. This impacts on the transferability of ReSPECT recommendations to the hospital setting.

Recognising the elephant in the room: Foundation doctors and anticipatory care planning.

Anticipatory/advance care planning (ACP) conversations are often known to be challenging and should be undertaken sensitively. A qualitative service evaluation was undertaken with the elderly care department at The Leeds Teaching Hospitals NHS Trust by medical students to explore the thoughts and experiences of foundation doctors. ACP discussions include consideration of future treatment options and preferences; however, foundation doctors were not confident to discuss issues beyond resuscitation status. The key themes identified include understanding of and confidence in ACP, variation across specialty and medical educational needs. The analysis highlights a further need for qualitative research into prevalent attitudes towards ACP discussions across the range of specialties.