Comparison of not for resuscitation (NFR) forms across five Victorian health services.
BACKGROUND
Within Australian hospitals, cardiac and respiratory arrests result in a resuscitation attempt unless the patient is documented as not for resuscitation.


OBJECTIVE
To examine the consistency of policies and documentation for withholding in-hospital resuscitation across health services.


METHODS
An observational, qualitative review of hospital policy and documentation was conducted in June 2013 in three public and two private sector hospitals in metropolitan Melbourne. Not for resuscitation (NFR) forms were evaluated for physical characteristics, content, authorisation and decision-making. Hospital policies were coded for alerts, definition of futility and burden of treatment and management of discussions and dissent.


RESULTS
There was a lack of standardisation, with each site using its own unique NFR form and accompanying site-specific policies. Differences were found in who could authorise the decision, what was included on the form, the role of patients and families, and how discussions were managed and dissent resolved. Futility and burden of treatment were not defined independently. These inconsistencies across sites contribute to a lack of clarity regarding the decision to withhold resuscitation, and have implications for staff employed across multiple hospitals.


CONCLUSIONS
NFR forms should be reviewed and standardised so as to be clear, uniform and consistent with the legislative framework. We propose a two-stage process of documentation. Stage 1 facilitates discussion of patient-specific goals of care and consideration of limitations of treatment. Stage 2 serves to communicate a NFR order. Decisions to withhold resuscitation are inherently complex but could be aided by separating the decision-making process from the communication of the decision, resulting in improved end-of-life care.
Cabrini-Monash University Department of Medicine, Cabrini Institute, Melbourne, Victoria, Australia; Cabrini-Monash University Clinical School, Melbourne, Victoria, Australia.
M
M
Levinson
A
A
Mills
A M
AM
Hutchinson
G
G
Heriot
G
G
Stephenson
A
A
Gellie
D006296:Health Services / Q000941:ethics / Q000592:standards*; D006760:Hospitalization; D006761:Hospitals / Q000941:ethics / Q000592:standards*; D006801:Humans; D016414:Resuscitation Orders / Q000941:ethics; D014739:Victoria / Q000453:epidemiology
cardiopulmonary resuscitation; decision-making; hospital communication system; resuscitation order; withholding treatment