title: Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions.
abstract: BACKGROUND
  The treatment for a cardiac arrest, cardiopulmonary resuscitation (CPR), may be lifesaving following an acute, potentially reversible illness. Yet this treatment is unlikely to be effective if cardiac arrest occurs as part of the dying process towards the end of a person's natural life. Do not attempt CPR (DNACPR) decisions allow resuscitation to be withheld when it has little chance of success, or where the patient, or those close to the patient, indicate the burdens of CPR outweigh the benefits. This review sought to identify evidence for systems that improve the appropriate use of DNACPR decisions.
  
  
  METHODS
  Electronic databases were searched (Medline, CINAHL and Embase) for English language articles from 2001 to 2014.
  
  
  RESULTS
  4090 citations were identified of which 37 studies were relevant. The overall quality of evidence was moderate to poor. Thematic synthesis identified key interventions which may improve DNACPR decision making. The most promising interventions involved structured discussion at the time of acute admission to hospital and review by specialist teams at the point of an acute deterioration. Linking DNACPR decisions to discussions about overall treatment plans provided greater clarity about goals of care, aided communication between clinicians and reduced harms. Standardised documentation proved helpful for improving the frequency and quality of recording DNACPR decisions. Patient and clinician education in isolation were associated with limited or no effects.
  
  
  CONCLUSIONS
  Relatively simple process changes may enhance the appropriate use of and outcomes associated with DNACPR decisions. Systematic review registration number: PROSPERO2012:CRD42012002669.
authors.affiliation: Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom; University of Warwick, Gibbett Hill, Coventry CV4 7AL, United Kingdom.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Field
authors.affiliation: University of Warwick, Gibbett Hill, Coventry CV4 7AL, United Kingdom; Department of Acute Medicine, Cambridge University Hospitals, United Kingdom.
authors.forename: Zoë
authors.initials: Z
authors.lastname: Fritz
authors.affiliation: Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom.
authors.forename: Annalie
authors.initials: A
authors.lastname: Baker
authors.affiliation: University of Warwick, Gibbett Hill, Coventry CV4 7AL, United Kingdom.
authors.forename: Amy
authors.initials: A
authors.lastname: Grove
authors.affiliation: Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom; University of Warwick, Gibbett Hill, Coventry CV4 7AL, United Kingdom. Electronic address: g.d.perkins@warwick.ac.uk.
authors.forename: Gavin D
authors.initials: GD
authors.lastname: Perkins
mesh_terms: D016887:Cardiopulmonary Resuscitation; D016208:Databases, Factual; D003657:Decision Making; D005260:Female; D006323:Heart Arrest / Q000401:mortality / Q000628:therapy; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care; D011369:Professional-Patient Relations; D016414:Resuscitation Orders / Q000941:ethics* / Q000331:legislation & jurisprudence; D013727:Terminal Care / Q000941:ethics / Q000379:methods*; D006113:United Kingdom
keywords: Do not attempt resuscitation; End of life care; Resuscitation orders; Treatment limitations