Ethics and Law

Background: This improvement activity was done within the Geriatrics/ Stroke department and aims to meet the following adopted standards: all DNACPR forms must be signed by a senior clinician and have clear documentation of the review status, if not “indefinite.’

Local problem: Incomplete DNACPR forms with lack of senior clinicians’ signature and unclear review status, which would affect clinical effectiveness of the document.

Methods: To gather baseline and post-intervention measurements, snapshot data was collected eighteen days apart to identify patients with a DNACPR in place that includes a senior clinician’s signature, and the appropriate review status based on the senior clinician’s plan.

Interventions: To implement changes, email communications were disseminated to Geriatrics/ Stroke team, and posters displayed in prominent locations around the respective hospital wards.

Results: A total of fifty patients were admitted to the Geriatrics and Stroke wards, of which thirty-four had a DNACPR form in place. Among these, 88.2% had a senior signed DNACPR form, while only 14.7% had the review status documented. Our goal was to achieve 90% of patients having a senior signature on their DNACPR forms and 45% having the appropriate review status at the end of the second cycle.

Conclusion: At the end of the second cycle, we successfully achieved our goal of ensuring that the majority of DNACPR forms had senior signatures and appropriate review status, demonstrating an effective improvement in compliance with the established standards for DNACPR documentation.

Introduction: Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision and plan for escalation of care are essential components of holistic care for frail and elderly patients. Inappropriate resuscitation attempts in those populations lead to distress and harm. Improving communication about end-of-life care plan between healthcare professionals and patients/ families is key to delivering dignified care and reducing emergency “inappropriate crash calls”.

Aim: The aim of this project was to assess and improve the completion rate of DNACPR forms and care escalation plans for patients admitted to medically stabilised beds in Singleton Hospital.

Methods: Two Plan-Do-Study-Act (PDSA) cycles were conducted: baseline project in July-August 2023 involving 34 patients and post-intervention project in October-November 2023 with 16 patients. Demographics data, Clinical Frailty Scores (CFS) and Charlson Comorbidity Index (CCI) and DNACPR status were collected. The intervention included introducing educational materials on medical wards and incorporating DNACPR status into patient handovers.

Results: 74% of patients had DNACPR plan in the pre-intervention group (who had mean age of 79 years, mean CFS 5.6, mean CCI 5.5). After intervention, a 7% improvement in DNACPR completion rate was observed. DNACPR plan was completed in 81% of patients (who had mean age of 80 years, mean CFS 5.75, mean CCI 5.6).

Conclusion: Whilst this initiative demonstrated an improvement in advanced care planning, 19% of patients in the post-intervention cycle still lacked appropriate escalation plans. Despite its limitations, this project raised awareness of health care professionals on DNACPR and ceiling-of-care decisions for frail elderly patients.

Aims

Understanding patients’ wishes regarding CPR before surgery is crucial. This study aims to assess the impact of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision on anaesthetists' actions during theatre.

Methods

We used WhatsApp, to present a scenario of an 83-year-old with ischemic heart disease, cognitive impairment, and an acute hip fracture. Anaesthetists were asked how they would handle various intraoperative events and whether a prior DNACPR decision would influence their actions.

Results

A total of 74 UK anaesthetists, all but one of them consultants, completed the anonymous survey. A surprising number N=27, (37%) of respondents indicated that prior knowledge of a DNACPR decision would have altered their preparedness to anaesthetise the patient.

Despite a pre-existing DNACPR decision N=68 (92%) stated that they would attempt electrical cardioversion if a patient became hypotensive with a regular broad complex tachycardia, as would N=65 (88%) in response to ventricular fibrillation during surgery. N=36 (49%) would initiate chest compressions in theatre if patient failed to respond to electrical cardioversion, but only N=2 (3%) would continue with intubation, ventilation and discussion with critical care if the patient failed to respond to three cycles of compressions and cardioversion.

Conclusion

It is important for anaesthetists to discuss the nuances of different elements of CPR as part of patients’ pre-operative assessment, as it is much more likely to be successful in theatre than in the ward or community settings that most DNACPR discussions will consider.

Raising the topic of resuscitation can lead to anxiety among patients and their families, Our study has shown that most anaesthetists will set aside a DNACPR decision anyway if problems arise in theatre.

Introduction:

The preference for place of death and the concept of dying in place have been subjects of debate in numerous jurisdictions. Despite the growing prevalence of ageing populations and the increasing demand for dying in place, there is a limited body of literature exploring older adults’ knowledge of dying in place and their preferences for the place of death. In Hong Kong, there are ongoing legislative efforts to revise the policy on dying in place. This study aims to investigate the knowledge of dying in place and the preferences for the place of death among older adults in Hong Kong.

Methods:

This cross-sectional study recruited 503 older adults. A questionnaire was disseminated through online social media platforms and face-to-face interview. ANOVA was conducted to compare the differences in knowledge scores among participants with varying preferences for the place of death.

Results:

Participants demonstrated a sub-optimal knowledge level (mean = 3.55; range 0-8). Notably, 54.7% of participants were unware of the existing law that regulates dying in place in Hong Kong, and 43.5% did not know about the availability of community resources to support patients who choose to die at home. The majority of participants (55.5%) preferred to die at home. Other preferences included hospital (18.9%), hospice (17.1%), and care home (8.5%). Participants who preferred to die at home exhibited a higher knowledge score (mean 3.84) compared to those who preferred to die in hospital (mean = 2.79) (F = 5.323, p = 0.001).

Conclusions:

The findings of this study provide insights that can inform the revision of current policies, the enhancement of community resources supporting dying in place, and the strengthening of life and death education targeted at older adults.

Acknowledgement:

The work described in this paper was fully supported by a fund from Hong Kong Metropolitan University (RD/2022/2.17).

Introduction:

In-hospital CPR has survival rates of 15-20%[BMA. Decisions on CPR, 3^rdedition, 2016], further reduced with frailty and multimorbidity. Successful CPR is associated with significant morbidity and prolonged suffering. Do not attempt resuscitation (DNACPR) is an advanced medical decision, aimed at preventing harm where CPR is considered futile.[GMC Guidance.p128-145]

Aims:

To reduce the burden of inappropriate CPR within surgical specialties using the following standards:

1. DNACPR status reviewed on admission, and all decisions implemented within 24hours of clerking.
2. DNACPR decisions implemented prior to surgery.
3. To assess clinician perceptions regarding DNACPR decisions.

Methods

This second cycle follows the intervention of a poster and departmental education in January 2020.

A survey was sent to clinicians of all grades in Trauma and Orthopaedics (T&O) and General Surgery in January 2023. Data on implementation of DNAR decisions was retrospectively collected over January and February 2023 for all T&O emergency and elective admissions >60-years-old.

Results

26 survey responses were obtained with all participants having had DNACPR discussions. 80.7% self-reported as confident/very confident in having these discussions.

Out of 264 patients included, 80 discussions took place, of which 64 (80%) were implemented. 69% were implemented within 24hours of clerking, a 23% increase from cycle 1. 90% of community DNACPRs (9/10) were applied within 24hours, however the one remaining patient received inappropriate CPR. Of the 47 patients with DNACPR who had surgery, 87% were implemented prior to surgery, a 12% increase from cycle 1.

Conclusion

Improvement was demonstrated on both standards between cycles. This QI focused on implementation of DNACPR following discussions, however, did not consider patients in whom DNACPR may have been appropriate but not discussed. Further areas to explore include appropriateness of CPR/ DNACPR decisions in advance of surgical interventions and the understanding behind limitations of treatment offered separate to CPR.