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Discussion and documentation of future care: a before-and-after study examining the impact of an alternative approach to recording treatment decisions on advance care planning in an acute hospital
  1. Alexandra C Malyon1,
  2. Julia R Forman2,
  3. Jonathan P Fuld3 and
  4. Zoë Fritz4
  1. 1 Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  2. 2 Applied Statistics and Epidemiology, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  3. 3 Respiratory and Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  4. 4 Acute Medicine, Cambridge University Hospitals NHS Foundation Trust and Warwick University, UK
  1. Correspondence to Alexandra C Malyon, Box 148 Cambridge University Hospitals, NHS Foundation Trust, Hill’s Road, Cambridge, CB2 0QQ, UK; amalyon{at}nhs.net

Abstract

Objective To determine whether discussion and documentation of decisions about future care was improved following the introduction of a new approach to recording treatment decisions: the Universal Form of Treatment Options (UFTO).

Methods Retrospective review of the medical records of patients who died within 90 days of admission to oncology or respiratory medicine wards over two 3-month periods, preimplementation and postimplementation of the UFTO. A sample size of 70 per group was required to provide 80% power to observe a change from 15% to 35% in discussion or documentation of advance care planning (ACP), using a two-sided test at the 5% significance level.

Results On the oncology ward, introduction of the UFTO was associated with a statistically significant increase in cardiopulmonary resuscitation decisions documented for patients (pre-UFTO 52% to post-UFTO 77%, p=0.01) and an increase in discussions regarding ACP (pre-UFTO 27%, post-UFTO 49%, p=0.03). There were no demonstrable changes in practice on the respiratory ward. Only one patient came into hospital with a formal ACP document.

Conclusions Despite patients’ proximity to the end-of-life, there was limited documentation of ACP and almost no evidence of formalised ACP. The introduction of the UFTO was associated with a change in practice on the oncology ward but this was not observed for respiratory patients. A new approach to recording treatment decisions may contribute to improving discussion and documentation about future care but further work is needed to ensure that all patients’ preferences for treatment and care at the end-of-life are known.

  • advance care planning
  • end of life
  • DNACPR
  • acute care
  • palliative care

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Footnotes

  • Contributors All authors contributed to the development of the study protocol, conduct of this research, analysis of the data and writing and revision of this paper.

  • Funding The research was funded by the National Institute for Health Research (NIHR) and supported by the Cambridge Biomedical Research Centre. ZF is grateful for support from the Wellcome Trust (grant number WT100557MA). ACM is grateful for support from a grant from the Burdett Trust for Nursing. This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0808–17218).

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • Competing interests ZF and JF, along with other colleagues, developed the Universal Form of Treatment Options. ZF was involved in the development of ReSPECT, and is on the Executive Committee of the Resuscitation Council(UK). The authors are not aware of any other existing conflicts of interest.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Approval for this study was obtained from the Cambridge East Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The authors are happy to make anonymised data from this study available to other researchers on request through contacting the corresponding author.

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