title: 'Why didn't you write a not-for-cardiopulmonary resuscitation order?' Unexpected death or failure of process?
abstract: Objective The aim of the present study was to understand the reasons for the delivery of non-beneficial cardiopulmonary resuscitation (CPR) attempts in a tertiary private hospital over 12 months. We determined doctors' expectations of survival after CPR for their patient, whether they had considered a not-for-resuscitation (NFR) order and the barriers to completion of NFR orders. Methods Anonymous questionnaires were sent to the doctors primarily responsible for a given patient's care in the hospital within 2 weeks of the unsuccessful CPR attempt. The data were analysed quantitatively where appropriate and qualitatively for themes for open-text responses Results Most doctors surveyed in the present study understood the poor outcome after CPR in the older person. Most doctors had an expectation that their own patient had a poor prognosis and a poor likely predicted outcome after CPR. This implied that the patient's death was neither unexpected nor likely to be reversible. Some doctors considered NFR orders, but multiple barriers to completion were cited, including the family's wishes, being time poor and diffusion or deferral of responsibility. Conclusions It is likely that futile CPR is provided contrary to policy and legal documents relating to end-of-life care, with the potential for harms relating to both patient and family, and members of resuscitation teams. The failure appears to relate to process rather than recognition of poor patient outcome. What is known about the topic? Mandatory CPR has been established in Australian hospitals on the premise that it will save lives. The outcome from in-hospital cardiac arrest has not improved despite significant training and resources. The outcome for those acutely hospitalised patients aged over 80 years has been repeatedly demonstrated to be poor with significant morbidity in the survivors. There is emerging literature on the extent of the delivery of non-beneficial treatments at the end of life, including futile CPR, the recognition of harms incurred by patients, families and members of the resuscitation teams and on the opportunity cost of the inappropriate use of resources. What does this paper add? This is the first study, to our knowledge, that has demonstrated that doctors understood the outcomes for CPR, particularly in those aged 80 years and older, and that failure to recognise poor outcome and prognosis in their own patients is not a barrier to writing NFR orders. What are the implications for practitioners? Recognition of the poor outcomes from CPR for the elderly patient for whom the doctor has a duty of care should result in a discussion with the patients, allowing an exploration of values and expectations of treatment. This would promote shared decision making, which includes the use of CPR. Facilitation of these discussions should be the focus of health service review.
authors.affiliation: Cabrini-Monash Department of Medicine, Cabrini Institute for Research and Education, 154 Wattletree Road, Malvern, Vic. 3144, Australia. Email: ;
authors.forename: Michele
authors.initials: M
authors.lastname: Levinson
authors.affiliation: Cabrini-Monash Department of Medicine, Cabrini Institute for Research and Education, 154 Wattletree Road, Malvern, Vic. 3144, Australia. Email: ;
authors.forename: Amber
authors.initials: A
authors.lastname: Mills
authors.affiliation: Intensive Care Unit, Epworth Healthcare, 89 Bridge Road, Richmond, Vic. 3121, Australia. Email.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Barrett
authors.affiliation: Cabrini-Monash Department of Medicine, Cabrini Institute for Research and Education, 154 Wattletree Road, Malvern, Vic. 3144, Australia. Email: ;
authors.forename: Gaya
authors.initials: G
authors.lastname: Sritharan
authors.affiliation: Cabrini-Monash Department of Medicine, Cabrini Institute for Research and Education, 154 Wattletree Road, Malvern, Vic. 3144, Australia. Email: ;
authors.forename: Anthea
authors.initials: A
authors.lastname: Gellie
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D016887:Cardiopulmonary Resuscitation / Q000523:psychology*; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D010820:Physicians / Q000523:psychology*; D011379:Prognosis; D016414:Resuscitation Orders / Q000523:psychology*; D018570:Risk Assessment; D011795:Surveys and Questionnaires; D013534:Survival / Q000523:psychology*; D062606:Tertiary Care Centers; D014739:Victoria / Q000453:epidemiology