key: cord-0743044-7qd77p42
authors: Coleman, Jamie J.; H Botkai, Adam; Marson, Ella J.; Evison, Felicity; Atia, Jolene; Wang, Jingyi; Gallier, Suzy; Speakman, John; Pankhurst, Tanya
title: Bringing into Focus Treatment Limitation and DNACPR Decisions: How COVID-19 has Changed Practice
date: 2020-08-20
journal: Resuscitation
DOI: 10.1016/j.resuscitation.2020.08.006
sha: 9483231fa77a556a4fb89a0f1f54f01f5eff38a9
doc_id: 743044
cord_uid: 7qd77p42

BACKGROUND: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR. METHODS: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions at are documented on an electronic healthcare records (EHR). Data from all DNACPR/TEAL status forms between 1(st) January 2017 and 30(th) April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019. RESULTS: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001). CONCLUSION: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

Cardiopulmonary resuscitation (CPR) is a potentially life-saving intervention for patients who go into cardiac arrest. It involves the provision of airway manoeuvres, artificial ventilation, external chest compressions, and, in some cases, electrical defibrillation, until J o u r n a l P r e -p r o o f further interventions can be implemented to help return of spontaneous circulation (ROSC).

CPR is an appropriate intervention in the case of sudden cardiac arrest in 'shockable' ventricular arrythmias (often due to acute myocardial ischaemia), but is less successful in cardiac arrests due to other causes which lead to 'non-shockable' rhythms. 1, 2 Distinguishing a sudden cardiac arrest from a cardiac cause in the context of a deterioration is difficult, and standard practice is usually to attempt CPR on any inpatient who has a cardiac arrest, regardless of the underlying cause. 1 Therefore, CPR is often attempted in many inpatients in whom there is little or no likelihood of benefit, as no anticipatory decisions were made about resuscitation status. 3 Non-maleficence is one of the four pillars of medical ethics and this principle of 'do no harm' is deeply engrained in the attitudes of healthcare professionals. 4 As such, protecting patients from unnecessary and potentially harmful procedures is an important aspect of healthcare provision. Whilst having the potential to prolong survival in some, for many patients CPR is at best futile and at worst degrading and physically harmful to a patient in the dying phase.

Even in successful CPR attempts, the effects of prolonged cerebral hypoxia can result in neurological deficits and a poor quality of life, suggesting that CPR may prolong death rather than prolong life. Due to the vigorous nature of chest compressions, there are also associated physical harms, including rib fractures, and airway manipulation may cause tracheal lesions. 5 The COVID-19 pandemic has further complicated the challenges surrounding the decision to perform CPR. As CPR is an aerosol generating procedure, guidance states that staff undertaking CPR should be wearing full personal protective equipment (PPE) to reduce the risk of COVID-19 transmission. 6, 7 The time taken to don PPE may delay CPR initiation and the use of bulky protective equipment can make it difficult to perform CPR with effective technique. Patients suffering from COVID-19 are most likely to deteriorate due to respiratory failure and/or sepsis. In an initial case series from Wuhan, China, the majority of cardiorespiratory arrests in COVID-19 inpatients were due to respiratory causes with asystole being the common presenting rhythm, hence long-term survival rates were minimal J o u r n a l P r e -p r o o f (3% survival at 30 days). 8 This rate of survival to hospital discharge is far lower than usual rates seen after in-hospital cardiac arrests in the United Kingdom. 9 Guidance from the National Institute of Health and Care Excellence during the COVID-19 pandemic has emphasised that a sensitive discussion should be undertaken in adult patients with capacity in whom an assessment suggests increased frailty (for example, a Clinical Frailty Score of 5 or more). 10 The possible benefits and risks of any critical care treatment options, including CPR, and the possible likely outcomes should be taken into account and form part of the joint decision-making process. These decisions are particularly important in terminally ill patients approaching the end of life, either from a chronic, irreversible disease or an acute, severe illness such as COVID-19.

A 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision is an aspect of care that provides guidance to medical staff regarding the appropriate course of action in the case of a cardiac arrest. DNACPR decisions may be put in place in the community ('community DNACPR') or in hospital, but are not legally binding or signed by the patient or a witness. Importantly, DNACPR decisions differ from an 'Advance Decision to Refuse Treatment' (ADRT), which is a legally binding document signed by the patient which details which interventions a patient wishes not to receive in the case that they are unable to express their preferences, and can include decisions around CPR.

Historically, treatment limitation decisions have only been considered in patients where treatment may be futile. Doctors may be hesitant to initiate these difficult conversations due to fear of causing distress or complaints. 11 However, due to the unpredictable nature of COVID-19 and who it may affect, at our hospital it was recommended that a conversation should be initiated with all inpatients surrounding ceilings of treatment and CPR, and document the subsequent decision. 2 In the UK, many health and social care providers use a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which documents the response to an emergency with a summary of recommendations to help make immediate decisions about a person's care and treatment. 12 The ReSPECT form is paper-based and many hospitals use J o u r n a l P r e -p r o o f this and other paper records to document decisions during patients' hospital stays.

However, as Electronic Healthcare Records (EHR) are rolled out in hospitals, DNACPR and Treatment Escalation and Limitation (TEAL) decisions are increasingly being documented electronically to provide high visibility and clear communication of the decisions. 13 Our institution has adopted DNACPR within the EHR since October 2011.

This study aims to analyse EHR documentation on treatment limitation and DNACPR decisions comparing uptake, decisions and answers to different sections of the form before and during the COVID-19 situation.

This analysis was conducted in a large, urban teaching hospital in the West Midlands, UK, with an in-house built clinically-led EHR, PICS (Prescribing, Information and Communication System), which has been described elsewhere. 14 Where decisions were recorded about resuscitation in a patient record during the COVID-19 period, patients were younger (79 years pre-COVID vs 74 years during COVID; p<0.001), less likely to have various co-morbidities and less likely to have a referral to the palliative care team (16.7% vs 28.5%; p<0.001) ( Table 1 ).

There were several findings that suggest that doctors' behaviours changed during the COVID-19 crisis. Not only were significantly more decisions taken around resuscitation, but questions were answered differently ( Where a decision was made that treatment should be limited, this was due to futility in most cases, with the remainder due to patient's wishes. Multiple reasons can be chosen, but reasons did not change significantly during COVID-19. However, there do appear to be fewer patients since COVID-19 with an advanced decision to refuse treatment (ADRT) (4.3% vs 1.7%, p=0.771).

The proportion of discussions that involved the patient remained similar, with 95.6%

in 2019 compared to 95.8% during COVID-19 (p=0.871). There was an increase in the proportion of patients with capacity to be involved in decisions (43.9% to 58.5%, p<0.001).

However, there was a significant decrease in DNACPR/TEAL decisions being discussed with the relatives -dropping from 75.4% to 50.6% (p<0.001).

There was a marginally significant change in when the review dates (7 days, 28 days or indefinite) were set for reviewing the DNACPR/TEAL decisions when initially completing the forms. 

The data would support the notion that clinicians have followed the recommendations to initiate treatment limitation conversations with more inpatients during this period. 1,844 decisions involving CPR were made in an eight-and-a-half-week period, compared to 14,163 in the previous 165 weeks, reflecting an increase in the mean proportion of inpatients who had a form completed from 20% to 50%.

The National Confidential Enquiry into Patient Outcome and Death suggested that clear documentation for ceilings of care facilitates early decision making and improves clarity of intent. 3 Nevertheless, it is apparent from this data that DNACPR forms were previously only completed in a small minority of patients in whom there is more likely to be an indication for treatment limitation. This suggests that there was a shift during the COVID-19 pandemic from undertaking decisions only in critically ill patients to a much wider group J o u r n a l P r e -p r o o f of inpatients. Of patients with treatment limitation documentation in place, clinicians previously believed 83% of patients were likely to die during admission in the similar period in 2019; this decreased to 70% during COVID-19. Similarly, during the pandemic 30.5% of patients were for full treatment, compared to 26.1% in 2019. This suggests that these conversations were being had with more patients who were not thought to be nearing the end of life and so CPR would be appropriate. This is supported by the fact that during COVID-19, patients who had a form in place were generally younger, had fewer comorbidities and were less likely to have a palliative care referral. This increase in discussions about treatment limitations with a wider patient group than usual seems very appropriate during a pandemic period. However, it is difficult to establish whether the threshold for a DNACPR decision has changed as there was a parallel increase in both form completion and DNACPR decisions in younger patients.

Reasons for patients not being for full active treatment were similar between the two time periods. However significantly fewer patients had an ADRT during the COVID-19 era, 1.7% compared with 4.3% in 2019. It is unclear whether this is a true lack of advanced decision making or purely a lack of communication of any advanced directive during this crisis period. It may also reflect the younger, fitter cohort who are less likely to have an ADRT in place.

Shared decision making is a concept that has grown in popularity in recent times. 15 Discussions around ceilings of care should involve patients where possible, and people should be included in decisions about their care. 16 The proportion of discussions that involved the patient was roughly similar. However, significantly more patients were deemed to have capacity, increasing from 43.9% to 58.5%. This is possibly due to the change from 

Patients' preferences continue to be documented; there has been a small decrease from 56.9% to 49.7% of clinicians documenting patient wishes. There is a shift from patients prioritising comfort to opting for life-sustaining treatments as shown in Figure 3 . As previously discussed, this may be due to an increase in these conversations with relatively well patients who are younger and therefore more likely to want full life-sustaining treatment. It is important to note that documenting patient wishes is not mandatory in the electronic form, thus explaining the overall low percentage of completion. Over 90% of decisions were discussed with the patient, therefore patient wishes may be considered but not explicitly documented in this form. Especially during times of increased pressure on clinicians' time, non-compulsory questions are likely to be ignored Documenting patient preferences should be encouraged to ensure that there is a shared understanding of where the balance between active medical interventions and comfort care is considered appropriate.

Patients may normally choose to involve their families in discussions surrounding ceilings of care. To reduce the spread of COVID-19 and maintain social distancing, during the pandemic visitors were no longer allowed in our hospital, apart from exceptional circumstances. This may explain the reduction in discussions with relatives from 75.4% to 50.6%, as they are no longer available for face-to-face discussions. Our experience suggested that treatment limitation discussions did tend to take place during patient admissions with their relatives by telephone as we employed dedicated family liaison personnel. However, these discussions were noted in the narrative patient record and not revisited on the DNACPR/TEAL status form. It is also possible that as a smaller proportion of patients are having decisions advising treatment limitation, that clinicians may decide that the decisions do not need to be discussed with the family, as full active treatment would be the care they would expect.

Although there is a statistically significant difference between the review date set between the pre-COVID era and during the pandemic, this may not be clinically significant as proportions were not dissimilar. Without greater scrutiny into the decision-making process of clinicians, it is difficult to establish the justifications for review date decisions. 

There are some limitations to this study. The information submitted on the electronic form is only what is reported at the time. It is possible that due to social responsibility bias that what was said to happen (discussion with patient and/or relatives) may not have actually happened. As with any electronic form it is impossible to uncover these responses, however we cannot see why COVID-19 would have considerably affected the rate of such responses. We only addressed the first DNACPR/TEAL form for each patient to prevent double counting responses. However, if a patient had several admissions during the time period, with different decisions on the DNACPR/TEAL this would have been missed.

Clinicians can re-enter and change the forms as many times as they like within an episode. Therefore, we miss the nuances of data if clinicians have altered forms when, for example, relatives have been communicated with at a later stage. Our experience tells us that even when communication by telephone happens with relatives, that people usually document this in the noting section of the EHR and do not re-enter the DNACPR/TEAL form itself.

Lastly, despite the positive response to early senior decision making in the COVID-19 pandemic, we will have to collect ongoing data to see if this effect is sustained in the post- J o u r n a l P r e -p r o o f 

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Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation

Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. National Confidential Enquiry into Patient Outcome and Death

Frequent and Rare Complications of Resuscitation Attempts

Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in acute hospital settings

COVID-19: personal protective equipment use for aerosol generating procedures

In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan

Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit

A survey of key opinion leaders on ethical resuscitation practices in 31 European Countries

Resuscitation Council (UK). ReSPECT [Online

A Unified Electronic Tool for CPR and Emergency Treatment Escalation Plans Improves Communication and Early Collaborative Decision Making for Acute Hospital Admissions

Implementation of rules based computerised bedside prescribing and administration: intervention study

Shared decision making: a model for clinical practice

Liberating the NHS: No decision about me, without me

Covid-19: Doctors still at "considerable risk" from lack of PPE