The impact of standardised goals of care documentation on the use of cardiopulmonary resuscitation, mechanical ventilation, and intensive care unit admissions in older patients: a retrospective observational analysis.

Background In South Australian hospitals, 'Do Not Resuscitate' orders have been replaced by '7-Step Pathway Acute Resuscitation Plans', a standardised form and approach that encourages shared decision-making while providing staff with clarity about goals of care. This initiative has led to increased rates of documentation about treatment preferences, including 'Not-For-Cardiopulmonary Resuscitation'. Aim To quantify any effect of the 7-Step Pathway form versus previous 'Do Not Resuscitate' orders on cardiopulmonary resuscitation, mechanical ventilation, and/or intensive care unit admission during hospitalisation. Methods We completed a retrospective, observational study in two Australian tertiary hospitals using interrupted time-series analysis. We examined the number of medical inpatients aged 70 years and over who received one or more Intensive Treatments-cardiopulmonary resuscitation, mechanical ventilation, or intensive care unit admission-in the 2 years before and 2 years after the introduction of the form. Results There were 2759 Intensive Treatments across 66 051 inpatient admissions; 1304/32 489 (4.0%) pre-intervention and 1455/33 562 post-intervention (4.3%). Sub-group analysis of those who died in hospital showed 400/1669 (24%) received Intensive Treatments pre-intervention and 382/1624 post-intervention (24%). Interrupted time-series analysis suggested that the intervention did not significantly alter Intensive Treatments over time at Hospital 1 and was associated with a significant slowing of the already decreasing use of Intensive Treatments at Hospital 2. Among patients who died in hospital, there was minimal change at either site. Conclusions There was no reduction in Intensive Treatments in older medical inpatients following the introduction of standardised goals of care documentation.

Moving from "Do Not Resuscitate" Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients.

Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient's treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely. This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.

The impact of language on the interpretation of resuscitation clinical care plans by doctors. A mixed methods study.

INTRODUCTION: Resuscitation clinical care plans (resuscitation plans) are gradually replacing 'Not for Cardiopulmonary Resuscitation' orders in the hospital setting. The 7-Step Pathway Resuscitation Plan and Alert form (7-Step form) is one example of a resuscitation plan. Treatment recommendations in resuscitation plans currently lack standardised language, creating potential for misinterpretation and patient harm. AIMS: To explore how terminology used in resuscitation plans is interpreted and applied by clinicians. METHOD: A mixed methods study surveyed 50 general medical doctors, who were required to interpret and apply a 7-Step form in three case vignettes and define seven key terms. Statistical analysis on multiple choice and thematic analysis on free-text responses was performed. RESULTS: Terminology was inconsistently interpreted and inconsistently applied, resulting in clinically significant differences in treatment choices. Three key themes influenced the application of a resuscitation plan: in-depth discussion, precise documentation and personal experience of the bedside deciding doctor. DISCUSSION: This study highlights persistent communication deficiencies in resuscitation plan documentation and how this may adversely affect patient care; findings unlikely to be unique to Australia or South Australia. CONCLUSION: Removing ambiguity by standardising and defining the terminology in resuscitation plans will improve bedside decision-making, while also supporting the rights of the patient to receive appropriate and desired care.

Changes in resuscitation and end-of-life documentation in older patients' clinical case notes: A comparison of 2011 and 2017 practice.

OBJECTIVE: To compare 2011 and 2017 documentation of resuscitation decisions in older patients, including the frequency and clarity of documentation. METHODS: The clinical case notes of 130 patients aged 70 years and over were examined to identify how resuscitation decisions are discussed and documented at a major teaching hospital. Results were compared to 2011 data. RESULTS: The proportion of patients with a documented order significantly increased, from 34 to 63%, with a concurrent increased number of patients identified as Not For Cardiopulmonary Resuscitation (Not for CPR). The standardised documentation has also improved rates of documented discussion, legibility and identification of the involved doctor. CONCLUSION: The Resuscitation Plan 7-Step Pathway has markedly improved the frequency of documented discussion, the rate of recorded Not For CPR status and clarity of documentation. There is scope for improvement as this policy is embraced across South Australia.