Background A 2014 court ruling in the UK established that the only justification for NOT discussing a “Do Not Attempt Cardiopulmonary Resuscitation”(DNACPR) order with a competent patient is either patient choice or potential “harm” to the patient (not distress).
Aims This study aimed to establish current practice in communication when making DNACPR decisions, the impact of the ruling and the interpretation of “harm”.
Methods The records of 150 hospice inpatients admitted after the ruling were screened. An anonymous survey was sent to hospice doctors and hospice nurses trained to complete DNACPR orders.
Results DNACPR decisions were made without discussion with competent patients in 6/150 cases. Reasons documented included: patient choice, the decision was implied from previous discussions, the patient was too unwell. All six decisions were discussed with the family.
Survey response rate was 90% (28/31) with equal numbers of specialist nurses and doctors. 21/28 respondents made DNACPR decisions at least monthly, 6/28 had made these decisions without discussion with a competent patient in the past six months, 20/28 were aware of the ruling and 16/28 felt it would impact on their practice.
Examples of impact on practice included; increased awareness of need to keep up-to-date, forcing earlier DNACPR discussions, pressure to discuss decisions with all patients, increased likelihood of exploring patient choice, increased involvement of family. Interpretations of “harm” included: more than distress, physical harm to self/others, psychiatric disorder, damage to doctor-patient relationship, distress close to the end-of-life.
Conclusions Only a minority of decisions were not discussed with competent patients. Not all relevant health care professionals are aware of the recent court ruling. Of those who were, over half felt it would impact upon their communication practice. There is a need for clarification of what constitutes harm rather than distress.
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