key: cord-0692482-4ucjbpyp authors: Connellan, D; Diffley, K; McCabe, J; Cotter, A; McGinty, T; Sheehan, G; Ryan, K; Cullen, W; Lambert, J S; Callaly, E L; Kyne, L title: Documentation of Do-Not-Attempt-Cardiopulmonary-Resuscitation Orders amid the COVID-19 Pandemic date: 2021-04-28 journal: Age Ageing DOI: 10.1093/ageing/afab075 sha: 94deb9604f4157c1fc51a6f2b9a03606784b9b76 doc_id: 692482 cord_uid: 4ucjbpyp Introduction: The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation (CPR) into focus. The aim of this study is to compare rates of Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. Methods: This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1(st) to May 31(s t) 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period and also compared to documentation rates pre-COVID-19 pandemic (March 1(st) to May 31(s t) 2019). Results: Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. Of 131 older (≥65 years) patients with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 older patients without COVID-19 (p < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p < 0.0001). Fifty percent of DNACPR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived. Conclusion: The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain good clinical practice despite the pandemic. Introduction: The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation (CPR) into focus. The aim of this study is to compare rates of Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. Methods: This was a retrospective repeated cross-sectional study. Data including comorbidities and resuscitation status was collected on 300 patients with COVID-19 The primary aim of this study is to audit the prevalence and timing associated with documentation of a DNACPR order in patients aged 65 years or over receiving inhospital care and diagnosed with COVID-19 in an academic teaching hospital in Ireland between 1 st March 2020 and 31 st May 2020. Secondary objectives of the study are to compare the prevalence of DNACPR orders in that population with the prevalence of DNACPR orders in two other populations: (i) patients aged ≥65 years who were hospitalised during the same time period but who did not have a diagnosis of COVID-19 (ii) patients aged ≥65 years who were hospitalised one year previously prior to onset of the pandemic. This was a retrospective repeated cross-sectional study conducted in a tertiary referral centre located in the north inner city of Dublin, Ireland [5] . This study utilised data from three sources: On analysis of 300 patients who were treated for COVID- Of the 79 patients aged ≥65 years with COVID-19, a DNACPR order was completed in 13 patients (16%) prior to the diagnosis. In those who had a DNACPR order documented after COVID-19 was diagnosed, the median time between a positive swab result for SARS-CoV-2 and order completion and was 1 day (range 0 to 45). Thirty-seven (47%) DNACPR orders were recorded in the electronic health record within 1 day of COVID-19 diagnosis. Of DNACPR decisions were associated with better end-of-life experiences alongside sensitive discussions and shared decision-making in a report on DNACPR decisions before and during the Coronavirus pandemic [8] . This report also highlighted that people had worse experiences when inappropriate or unwanted CPR was attempted or when communication of DNACPR decisions was poor or non-existent. We recognise a number of limitations of our study. In our institution, DNACPR orders are completed on the electronic health record. However, the documentation is only completed when a DNACPR order is put in place, and there is no electronic documentation of advanced care planning discussions where the outcome is that it is agreed that a DNACPR order should not be put in place. Therefore, we cannot infer from our data whether there was a change in the frequency with which advance care planning discussions were held. On comparison of DNACPR documentation rates between groups with and without COVID-19, and to before the pandemic, baseline co-morbidities and admission details were not recorded in the HIPE groups. We note that the differences in prevalence of DNACPR documentation could arise from this but the significant increase of documentation in COVID-19 patients remains striking. Our National and institutional DNACPR policy encourages discussion of all decisions with patients and/or families however this information is frequently filled out on a printed DNACPR form and was not available to us electronically. Therefore 'patient preferences' as a factor associated with DNACPR was not captured. We do however recognise the importance of these discussions in determining a person's goals and preferences regarding resuscitation [1] . Further research is needed to provide insight into the behavioural characteristics associated with changes in DNACPR practice, the processes of decision-making and the personal impact on patients and families. It is essential that DNACPR decisions are made in ways that protect human rights and meet the individual needs of patients even during times of maximum challenge to healthcare systems. U N C O R R E C T E D M A N U S C R I P T Guidance Regarding Cardiopulmonary Resuscitation and DNAR Decision-Making during the COVID-19 Pandemic Do-notattempt-resuscitation (DNAR) orders: understanding and interpretation of their use in the hospitalised patient in Ireland. A brief report Interpretation and intent: A study of the (mis)understanding of DNAR orders in a teaching hospital Ethical Framework for Decision Making in a Pandemic About Us | The Mater Hospital What is the clinical course of patients hospitalised for COVID-19 treatment Ireland: a retrospective cohort study in Dublin's North Inner City (the 'Mater Multimorbidity: Technical Series on Safer Primary Care. Geneva: World Health Organization Better understanding, better outcomes: what we've learned about DNACPR decisions before and during the Coronavirus pandemic