Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice

Jamie J Coleman; Adam Botkai; Ella J Marson; Felicity Evison; Jolene Atia; Jingyi Wang; Suzy Gallier; John Speakman; Tanya Pankhurst

doi:10.1016/j.resuscitation.2020.08.006

Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice

Jamie J Coleman, Adam Botkai, Ella J Marson, Felicity Evison, Jolene Atia, Jingyi Wang, Suzy Gallier, John Speakman, Tanya Pankhurst

Research output: Contribution to journal › Article › peer-review

Abstract

BACKGROUND: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR.

METHODS: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019.

RESULTS: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001).

CONCLUSION: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

Original language	English
Pages (from-to)	172-179
Number of pages	8
Journal	Resuscitation
Volume	155
DOIs	https://doi.org/10.1016/j.resuscitation.2020.08.006
Publication status	Published - Oct 2020

Bibliographical note

Keywords

Aged
COVID-19
Cardiopulmonary Resuscitation/methods
Clinical Decision-Making/ethics
Cohort Studies
Coronavirus Infections/epidemiology
Critical Illness/mortality
Databases, Factual
Delivery of Health Care/trends
Female
Hospital Mortality/trends
Hospitals, Teaching
Humans
Incidence
Male
Middle Aged
Pandemics/prevention & control
Pneumonia, Viral/epidemiology
Resuscitation Orders/ethics
Retrospective Studies
United Kingdom

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10.1016/j.resuscitation.2020.08.006

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title = "Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice",

abstract = "BACKGROUND: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR.METHODS: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019.RESULTS: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001).CONCLUSION: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.",

keywords = "Aged, COVID-19, Cardiopulmonary Resuscitation/methods, Clinical Decision-Making/ethics, Cohort Studies, Coronavirus Infections/epidemiology, Critical Illness/mortality, Databases, Factual, Delivery of Health Care/trends, Female, Hospital Mortality/trends, Hospitals, Teaching, Humans, Incidence, Male, Middle Aged, Pandemics/prevention & control, Pneumonia, Viral/epidemiology, Resuscitation Orders/ethics, Retrospective Studies, United Kingdom",

author = "Coleman, {Jamie J} and Adam Botkai and Marson, {Ella J} and Felicity Evison and Jolene Atia and Jingyi Wang and Suzy Gallier and John Speakman and Tanya Pankhurst",

year = "2020",

month = oct,

doi = "10.1016/j.resuscitation.2020.08.006",

language = "English",

volume = "155",

pages = "172--179",

journal = "Resuscitation",

issn = "0300-9572",

publisher = "Elsevier",

}

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T1 - Bringing into focus treatment limitation and DNACPR decisions

T2 - How COVID-19 has changed practice

AU - Coleman, Jamie J

AU - Botkai, Adam

AU - Marson, Ella J

AU - Evison, Felicity

AU - Atia, Jolene

AU - Wang, Jingyi

AU - Gallier, Suzy

AU - Speakman, John

AU - Pankhurst, Tanya

PY - 2020/10

Y1 - 2020/10

N2 - BACKGROUND: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR.METHODS: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019.RESULTS: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001).CONCLUSION: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

AB - BACKGROUND: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR.METHODS: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019.RESULTS: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001).CONCLUSION: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

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KW - COVID-19

KW - Cardiopulmonary Resuscitation/methods

KW - Clinical Decision-Making/ethics

KW - Cohort Studies

KW - Coronavirus Infections/epidemiology

KW - Critical Illness/mortality

KW - Databases, Factual

KW - Delivery of Health Care/trends

KW - Female

KW - Hospital Mortality/trends

KW - Hospitals, Teaching

KW - Humans

KW - Incidence

KW - Male

KW - Middle Aged

KW - Pandemics/prevention & control

KW - Pneumonia, Viral/epidemiology

KW - Resuscitation Orders/ethics

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DO - 10.1016/j.resuscitation.2020.08.006

M3 - Article

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SN - 0300-9572

VL - 155

SP - 172

EP - 179

JO - Resuscitation

JF - Resuscitation

ER -

Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice

Abstract

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