Journal articles: 'Resuscitation Orders'

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Bowman, Sallyann M. "Resuscitation Orders." Annals of Internal Medicine 111, no. 12 (December 15, 1989): 1046. http://dx.doi.org/10.7326/0003-4819-111-12-1046_1.

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Alison, DL. "Resuscitation and non-resuscitation orders." Palliative Medicine 8, no. 1 (January 1994): 79. http://dx.doi.org/10.1177/026921639400800113.

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Skinner, Andrew. "Resuscitation and non-resuscitation orders." Palliative Medicine 8, no. 4 (October 1994): 338–39. http://dx.doi.org/10.1177/026921639400800413.

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Swartz, Conrad M., and Carole Stewart. "Melancholia and Orders to Restrict Resuscitation." Psychiatric Services 42, no. 2 (February 1991): 189–91. http://dx.doi.org/10.1176/ps.42.2.189.

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Sritharan, Gaya, Amber C. Mills, Michele R. Levinson, and Anthea L. Gellie. "Doctors’ attitudes regarding not for resuscitation orders." Australian Health Review 41, no. 6 (2017): 680. http://dx.doi.org/10.1071/ah16161.

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Objectives The aims of the present study were to investigate doctors’ attitudes regarding the discussion and writing of not for resuscitation (NFR) orders and to identify potential barriers to the completion of these orders. Methods A questionnaire-based convenience study was undertaken at a tertiary hospital. Likert scales and open-ended questions were directed to issues surrounding the discussion, timing, understanding and writing of NFR orders, including legal and personal considerations. Results Doctors thought the presence of an NFR order both should and does alter care delivered by nursing staff, particularly delivery of pain relief, nursing observations and contacting the medical emergency team. Eighty-five per cent of doctors believed they needed somebody else’s consent to write an NFR order (seeking of consent is not a requirement in most Australian jurisdictions). Conclusion There are complex barriers to the writing and implementation of NFR orders, including doctors’ knowledge around the need for consent when cardiopulmonary resuscitation is likely to be futile or excessively burdensome. Doctors also believed that NFR orders result in changes to goals-of-care, suggesting a confounding of NFR orders with palliative care. Furthermore, doctors are willing to write NFR orders where there is clear medical indication and the patient is imminently dying, but are otherwise reliant on patients and family to initiate discussion. What is known about the topic? Hospitalised elderly patients, in the absence of an NFR order, are known to have poor survival and outcomes following resuscitation. Further, Australian data on the prevalence of NFR forms show that only a minority of older in-patients have a written NFR order in their history. In Australian hospitals, NFR orders are completed by doctors. What does this paper add? To our knowledge, the present study is the first in Australia to qualitatively analyse doctors’ reasons to writing NFR orders. The open-text nature of this questioning has been important in eliciting doctors’ responses without hypothesis guessing bias. Further, we add to the literature on the breadth of considerations doctors may encounter with regard to NFR orders. What are the implications for practitioners? The findings indicate the issues impeding decision making around cardiopulmonary resuscitation relate to poor knowledge of the law, particularly around the issue of consent and confounding NFR orders with provision of palliative care. Such barriers to the completion of NFR orders expose elderly in-patients to futile and burdensome resuscitation events. The findings suggest consideration be given to education and training materials to inform doctors about jurisdictional law regarding resuscitation documentation, support decision making around cardiopulmonary resuscitation and promote goals-of-care discussions on admission.

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Halliwell, Amanda. "DNAR orders during the pandemic." Practice Management 31, no. 1 (January 2, 2021): 32–35. http://dx.doi.org/10.12968/prma.2021.31.1.32.

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The Care Quality Commission was commissioned by the Department of Health and Social care to review do not attempt resuscitation decision-making during the Covid-19 pandemic. Amanda Halliwell reviews their interim report

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Kalkman, Shona, Lotty Hooft, Johanne M. Meijerman, Johannes T. A. Knape, and Johannes J. M. van Delden. "Survival after Perioperative Cardiopulmonary Resuscitation." Anesthesiology 124, no. 3 (March 1, 2016): 723–29. http://dx.doi.org/10.1097/aln.0000000000000873.

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Abstract Automatic suspension of do-not-resuscitate (DNR) orders during general anesthesia does not sufficiently address a patient’s right to self-determination and is a practice still observed among anesthesiologists today. To provide an evidence base for ethical management of DNR orders during anesthesia and surgery, the authors performed a systematic review of the literature to quantify the survival after perioperative cardiopulmonary resuscitation (CPR). Results show that the probability of surviving perioperative CPR ranged from 32.0 to 55.7% when measured within the first 24 h after arrest with a neurologically favorable outcome expectancy between 45.3 and 66.8% at follow-up, which suggests a viable survival of approximately 25%. Because CPR generally proves successful in less than 15% of out-of-hospital cardiac arrests, the altered outcome probabilities that the conditions in the operating room bring on warrant reevaluation of DNR orders during the perioperative period. By preoperatively communicating the evidence to patients, they can make better informed decisions while reducing the level of moral distress that anesthesiologists may experience when certain patients decide to retain their DNR orders.

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Griffith, Richard. "Consultation before ‘do not attempt resuscitation’ orders." British Journal of Nursing 28, no. 13 (July 11, 2019): 886–87. http://dx.doi.org/10.12968/bjon.2019.28.13.886.

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Morrison, Wynne, and Ivor Berkowitz. "Do Not Attempt Resuscitation Orders in Pediatrics." Pediatric Clinics of North America 54, no. 5 (October 2007): 757–71. http://dx.doi.org/10.1016/j.pcl.2007.06.005.

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Micallef, S., M. Skrifvars, and M. J. Parr. "Barriers to documenting not-for-resuscitation orders." Resuscitation 81, no. 2 (December 2010): S33—S34. http://dx.doi.org/10.1016/j.resuscitation.2010.09.143.

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Hill, Jo, Adam Gerace, Candice Oster, and Shahid Ullah. "Resuscitation status in psychogeriatric and general medical inpatients aged 65 years and older: a retrospective comparison study." Australian Health Review 43, no. 4 (2019): 432. http://dx.doi.org/10.1071/ah18004.

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Objective The aims of the present study were to establish rates of resuscitation order documentation of patients aged ≥65 years from both psychogeriatric and general medical units and to compare patients on predictors of resuscitation status, particularly examining the effect of depression. Methods A retrospective case note audit of psychogeriatric (n=162) and general medical (n=135) unit admissions within a tertiary teaching hospital was performed. Multivariate logistic regression was used to determine significant clinical and demographic predictors of resuscitation status. Results Resuscitation orders were documented in more psychogeriatric (94.4%) than general medical (48.1%) files. Depression did not significantly predict resuscitation status in either group. Having undergone competency assessment significantly predicted resuscitation status for the total sample and separately for psychogeriatric and medical patients. Older age (overall sample), poorer prognosis (overall sample), living in residential care (overall sample and medical group) and self-consenting to resuscitation status (overall sample and medical group) significantly predicted resuscitation status. Conclusions Resuscitation orders were more frequently documented on the psychogeriatric unit. Further prospective analysis is needed of how resuscitation orders are made before depression is discounted as a predictor of end-of-life decision-making. What is known about the topic? Despite increased community, media and research attention to end-of-life decision-making, resuscitation preferences of older patients are often poorly documented. Existing research into patient clinical and demographic factors that influence end-of-life decision-making have largely focused on general medical rather than psychogeriatric settings. There is a need to investigate rates of resuscitation documentation in psychogeriatric and general medical units and specific factors associated with having a ‘do not attempt resuscitation’ order in place, particularly the effect of current depression on decision-making. What does this paper add? Resuscitation orders were more frequently documented on the psychogeriatric than medical unit. Depression was not a significant predictor of resuscitation status in either group of patients. Although having undergone a competency assessment, older age and poorer prognosis predicted not being for resuscitation for the total sample, living in residential care and self-consenting to resuscitation status predicted not being for resuscitation for the overall sample and the medical group specifically. What are the implications for practitioners? This paper suggests that the need for clinicians to ensure documentation of preferences is a focus of day-to-day work with older patients. Clinicians should consider patient competency in end-of-life decision-making and how factors associated with depression, such as helplessness, may be more closely related to resuscitation decision-making in older patients.

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Ebrahim, Shah. "Cardiopulmonary resuscitation and do not attempt resuscitation orders: legislation may be helpful." Clinical Medicine 2, no. 1 (January 1, 2002): 79–80. http://dx.doi.org/10.7861/clinmedicine.2-1-79.

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Vancini-Campanharo, Cássia Regina, Rodrigo Luiz Vancini, Marcelo Calil Machado Netto, Maria Carolina Barbosa Teixeira Lopes, Meiry Fernanda Pinto Okuno, Ruth Ester Assayag Batista, and Aécio Flávio Teixeira de Góis. "Do not attempt resuscitation orders at the emergency department of a teaching hospital." Einstein (São Paulo) 15, no. 4 (December 2017): 409–14. http://dx.doi.org/10.1590/s1679-45082017ao3999.

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ABSTRACT Objective: To identify factors associated with not attempting resuscitation. Methods: A cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05). Results: No cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole. Conclusion: Advanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

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McNeill, D., B. Mohapatra, J. Y. Z. Li, D. Spriggs, S. Ahamed, Y. Gaddi, P. Hakendorf, D. I. Ben-Tovim, and C. H. Thompson. "Quality of resuscitation orders in general medical patients." QJM 105, no. 1 (August 24, 2011): 63–68. http://dx.doi.org/10.1093/qjmed/hcr137.

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Slowther, Anne-Marie. "Medical futility and 'Do Not Attempt Resuscitation' orders." Clinical Ethics 1, no. 1 (March 1, 2006): 18–20. http://dx.doi.org/10.1258/147775006776173336.

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Lake, Rachel Elisabeth, Lori Franks, and Barry Meisenberg. "Reducing Discrepancy Between Code Status Orders and Physician Orders for Life-Sustaining Therapies: Results of a Quality Improvement Initiative." American Journal of Hospice and Palliative Medicine® 37, no. 7 (January 9, 2020): 532–36. http://dx.doi.org/10.1177/1049909119899079.

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Background: Advanced care planning through Physician Order For Life-Sustaining Therapies (POLST) has been encouraged by professional societies. But these documents may be overlooked or ignored during hospitalization and “full-code” orders written as a default, putting patients at risk for unwanted resuscitation. After 2 instances of unwanted resuscitation in which limited support POLSTs were ignored, a series of improvements were implemented. This study measured the effectiveness of those steps in reducing POLST code status discrepancy. Methods: Pre–post implementation chart review of randomly chosen medical admissions to determine the rate of discordance between POLST orders (when present) and admission code status orders. Physician Order For Life-Sustaining Therapies were classified as either “full” or “limited” based on orders for life-sustaining therapies on the form. Chi-square tests or Fisher exact tests were performed on binary data to identify statistically significant differences at the 95% confidence level between pre- and postimplementation admissions. Results: In all, 444 preimplementation and 448 postimplementation admissions were evaluated. Discrepant code status orders for those with limited POLST fell from 10 (22.7%) of 44 preimplementation to 3 (4.6%) of 65 after implementation, P = .006. The number of documented code status discussions in admission notes increased from 19.6% to 63.6% ( P < .001). The median age of all POLST in the chart was 1.2 years. Conclusions: Among those patients with limited POLST orders, discrepant full-code orders increase the potential for unwanted resuscitation. Multistep improvements including documentation templates improved the process of verifying end-of-life wishes and increased meaningful code status discussions. The rate of discrepant orders fell in response to process improvements.

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Emuron, Dennis Omoding, Milos Miljkovic, Lori Rhodes, Joseph Abraham, and Kenneth David Miller. "Are “Allow Natural Death” orders preferable to “Do Not Resuscitate” orders for patients with advanced cancer?" Journal of Clinical Oncology 31, no. 15_suppl (May 20, 2013): e20685-e20685. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.e20685.

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e20685 Background: Over twenty years after the passage of the Patient Self-Determination Act, patients’ preferences regarding end-of-life (EOL) care are often unknown to physicians. The aim of this study was to assess the knowledge and attitudes of cancer patients regarding EOL care, and to compare “Do Not Resuscitate” (DNR) and “Allow Natural Death” (AND) orders. Methods: Adult patients with advanced cancer were invited to participate. The first 50 consenting patients were surveyed regarding their prognosis and attitudes about critical care and resuscitation. We presented them with hypothetical scenarios in which a decision on their code status had to be made if they had 1 year, 6 months or 1 month left to live. Twenty-five patients were given a choice between being “full code" and DNR, and then 25 patients had a choice between "full code" and AND. Results: Almost half the patients (49%) were not aware that their illness was terminal. Fifty percent reported having a living will. However, only 19% reported that their doctors knew their wishes regarding EOL care. In contrast, greater than 78% reported knowledge of intubation, tracheotomy, feeding tubes, and cardiopulmonary resuscitation (CPR). The proportions of participants choosing full resuscitation compared to the DNR or AND options did not differ significantly from 50% (p-values > 0.54). Their choices did not vary by age, sex, race, type of cancer, education or income level (p-values > 0.05). Patients' attitudes towards CPR, tracheostomy and feeding tubes were not significantly associated with their choice of "DNR" (p-values > 0.17), but those who wanted these interventions were significantly less likely to choose "AND" (p-values < 0.002). As many as 38% of the patients without a living will chose "DNR", while 11% opted for "AND" (p-values < 0.03). Conclusions: In this small sample of patients with advanced cancer many were unaware of their poor prognosis, and few informed their physicians of their EOL preferences. The wording of DNR and AND orders was not associated with patients' EOL preferences. Contrary to our expectation, the "Allow Natural Death" phrasing might be less acceptable to patients who view life-prolonging measures favorably.

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Linticum, Kim, Shawn P. Fagan, Bounthavy F. Homsombath, Lynn Dowling, and Mandy Rhodes. "558 Nurse-driven fluid resuscitation protocol - a quality improvement initiative." Journal of Burn Care & Research 43, Supplement_1 (March 23, 2022): S114—S115. http://dx.doi.org/10.1093/jbcr/irac012.186.

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Abstract Introduction The migration of paper medical records to electronic health record (EHR) has been in process for a few years now and most facilities have achieved this successfully. EHR has streamlined care and documentation. Further developments such as Computerized Physician Order Entry (CPOE) has been noted as one of the most promising functionalities of Health Information Technology (HIT), as it allows providers to enter orders, medications, diagnostic tests, and procedures, with the intent of improving the clarity and specificity of physician orders, facilitating the rapid communication of orders to pharmacies, and providing significantly enhanced decision support capabilities compared to traditional handwritten orders.1 In our experience, initiation of CPOE has been beneficial in many ways, namely in decreasing medication errors related to handwritten orders. However, in the clinical scenario of acute resuscitation of a critically injured burn patient, the CPOE structure did not address each and every need that would arise, especially if fluid titration was necessary. Nursing staff were left unsure of what to do in terms of their role in adjusting fluids and assessing for adequacy of resuscitation. This led to gaps in care in which potential critical situations needed to be addressed. For instance, the possible development of abdominal compartment syndrome and how to respond to it was not part of CPOE set that was implemented. This was placing the patient at risk by delaying initiation of hemodynamic monitoring and delaying electrolyte replacement as well. The goal of this study is to report the outcomes of this quality improvement initiative and to describe the resultant research that is in place to evaluate its effectiveness. Methods This is a QI project that will identify and describe how a protocol was developed post- CPOE implementation to address gaps in nursing care during fluid resuscitation of critically ill burned patients Results We created a protocol that allows the nurse to have better insight into what is happening with the patient and what physician orders are most pertinent at any particular time. The protocol sets parameters that alerts the nurse when additional intervention is necessary. For instance, monitoring for abdominal compartment syndrome begins once resuscitation exceeds 6 mL/kg/TBSA and allowing for the nurse to call the primary physician for hypotension that is refractory to fluid bolus. This was not clear before and nurses were not intervening appropriately, which resulted in gaps in delivery of care. We have not had to report any adverse or sentinel event related to fluid resuscitation since the implementation of this protocol. Conclusions A nurse-driven protocol helped address gaps in care for nurses at the bedside during fluid resuscitation

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Sritharan, G., M. Levinson, A. Mills, and A. Gellie. "P-26 Doctors’ attitudes towards not for resuscitation orders." BMJ Supportive & Palliative Care 5, Suppl 2 (September 2015): A51.1—A51. http://dx.doi.org/10.1136/bmjspcare-2015-000978.156.

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Li, J. Y. Z., T. Y. Yong, P. Hakendorf, D. Ben-Tovim, and C. H. Thompson. "The survival of patients with not-for-resuscitation orders." QJM: An International Journal of Medicine 106, no. 10 (May 28, 2013): 903–7. http://dx.doi.org/10.1093/qjmed/hct120.

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Casarett, David, and Mark Siegler. "Unilateral do-not-attempt-resuscitation orders and ethics consultation." Critical Care Medicine 27, no. 6 (June 1999): 1116–20. http://dx.doi.org/10.1097/00003246-199906000-00031.

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Zacharski, Susan, Lindsey Minchella, Sue Gomez, Sheila Grogan, Stephanie Porter, and Deb Robarge. "Do Not Attempt Resuscitation (DNAR) Orders in School Settings." NASN School Nurse 28, no. 2 (January 24, 2013): 71–75. http://dx.doi.org/10.1177/1942602x12472540.

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Mills, Amber, Anne Walker, Michele Levinson, Alison M. Hutchinson, Gemma Stephenson, Anthea Gellie, George Heriot, Harvey Newnham, and Megan Robertson. "Resuscitation orders in acute hospitals: A point prevalence study." Australasian Journal on Ageing 36, no. 1 (October 19, 2016): 32–37. http://dx.doi.org/10.1111/ajag.12354.

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Gibbs, N. M. "Anaesthesia, Not for Resuscitation Orders, and Shared Decision-Making." Anaesthesia and Intensive Care 45, no. 3 (May 2017): 289–90. http://dx.doi.org/10.1177/0310057x1704500303.

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Griffith, Richard. "Do not attempt resuscitation orders in primary care settings." British Journal of Community Nursing 23, no. 6 (June 2, 2018): 252–54. http://dx.doi.org/10.12968/bjcn.2018.23.6.252.

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Griffith, Richard. "Do not attempt resuscitation orders in primary care settings." British Journal of Community Nursing 23, no. 6 (June 2, 2018): 304–6. http://dx.doi.org/10.12968/bjcn.2018.23.6.304.

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Hassan, Chamsi Pasha, and Albar Mohammed Ali. "Do-Not-Resuscitate Orders: Islamic viewpoint." International Journal of Human and Health Sciences (IJHHS) 2, no. 1 (February 1, 2018): 8. http://dx.doi.org/10.31344/ijhhs.v2i1.18.

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It is imperative to seek remedy in life-threatening situations. When treatment benefit is doubted, seeking remedy becomes facultative. If the treatment is futile, there is no need to continue. Resuscitation has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort, and consume resources. The do-not-resuscitate (DNR) order and advance directives are still a debated issue in critical care patients.The DNR order in the case of terminal illness is encouraged in Islam.International Journal of Human and Health Sciences Vol. 02 No. 01 Jan’18. Page : 8-12

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Dignam, Colette, Margaret Brown, and Campbell H. Thompson. "Moving from “Do Not Resuscitate” Orders to Standardized Resuscitation Plans and Shared-Decision Making in Hospital Inpatients." Gerontology and Geriatric Medicine 7 (January 2021): 233372142110034. http://dx.doi.org/10.1177/23337214211003431.

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Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely. This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.

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Sherbino, Jonathan, Veena Guru, P. Richard Verbeek, and Laurie J. Morrison. "Prehospital emergency medical services’ ethical dilemma with do-not-resuscitate orders." CJEM 2, no. 04 (October 2000): 246–51. http://dx.doi.org/10.1017/s1481803500007272.

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ABSTRACT Objective: Our primary objectives were to estimate how frequently emergency medical technicians with defibrillation skills (EMT-Ds) are forced to deal with prehospital do-not-resuscitate (DNR) orders, to assess their comfort in doing so, and to describe the prehospital care provided to patients with DNR orders in a system without a prehospital DNR policy (i.e., where resuscitation is mandatory). Methods: Using Dillman methodology, the authors developed a 13-item survey and mailed it to 382 of 764 EMT-Ds in the metropolitan Toronto area. Responses were evaluated using 5-point Likert scales, limited-option and open-ended questions. Narrative responses were categorized. Two authors independently categorized narrative responses from 20 surveys, and kappa values for agreement beyond chance were determined. Results: Among 382 EMT-Ds surveyed, 236 (62%) responded, of whom 221 (94%) answered the questionnaire. Overall, 126 of 219 (58%) indicated that they were called to resuscitate patients with DNR orders “sometimes,” “frequently,” or “all the time.” In such situations, 22 of 207 (11%) stated they would honour the DNR order and 55 of 207 (27%) would honour the order but appear to provide basic resuscitation, in order to adhere to mandatory resuscitation regulations. Willingness to honour a DNR order did not vary by years of emergency medical service. EMT-Ds cited concern for the family and the patient, fear of repercussions and conflict with personal ethics as key factors contributing to this ethical dilemma. If legally allowed to honour DNR orders, 212 of 221 (96%) respondents would be comfortable with a written order and 137 of 220 (62%) with a verbal order. Conclusion: Prehospital DNR orders are common, and a significant number of EMT-Ds disregard current regulations by honouring them. EMT-Ds would be more comfortable with written than verbal DNR orders. An ethical prehospital DNR policy should be developed and applied.

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Griffith, Richard. "COVID-19 and the lawfulness of bulk do not attempt resuscitation orders." British Journal of Nursing 29, no. 17 (September 24, 2020): 1042–43. http://dx.doi.org/10.12968/bjon.2020.29.17.1042.

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Embliss, Liam, and Mohan Bhat. "To resuscitate or not to resuscitate; a question for old age psychiatrists." BJPsych Open 7, S1 (June 2021): S21—S22. http://dx.doi.org/10.1192/bjo.2021.113.

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AimsThe inpatient population of an older adult psychiatric ward will include people with physical and mental health conditions which affect life span and quality of life. Patients may be frail, acutely unwell, or have terminal illnesses such as dementia. It is therefore essential that clinicians review resuscitation status as part of their routine practice. However, we are aware that advanced decision-making – to resuscitate or not to resuscitate – is not routine practice across older adult psychiatric wards in the UK. Our 2017 audit reflected this, demonstrating a very low rate of resuscitation decisions at NELFT.This re-audit aimed to measure the frequency and quality of resuscitation decisions on an older adult psychiatric ward. We expected improvements in these areas, subsequent to changes implemented from the initial audit. We also sought to identify which patient factors influenced clinicians’ decision-making on resuscitation.Please note, this audit was completed prior to the COVID-19 pandemic.MethodIn June 2017, an audit of 25 patients admitted to two older adult psychiatric acute wards was completed. In December 2019, a retrospective analysis of the last 25 admissions to one older adult ward was undertaken. Electronic patient notes and DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) orders were examined. The audit measured frequency of resuscitation decisions and quality of documentation against current standards. DNACPR orders were analysed and clinicians were interviewed to identify the reasons for such decisions.ResultThere was an increase in the number of patients for which resuscitation decisions were made, from 4% in 2017 to 40% (n = 10) in 2019. The majority of patients with a DNACPR decision (n = 8) had a diagnosis of dementia. Prospective quality of life, with this diagnosis, was the most frequent determinant of DNACPR decisions (n = 7). Qualitative analysis indicated that clinicians were more likely to consider a resuscitation decision for patients with an organic disorder rather than functional disorder.Adequate completion of DNACPR orders was seen in each case. Either the patient, a family member or carer was involved in every decision. The standard for recording decisions on the electronic patient record was not met.ConclusionIt is good practice to consider resuscitation decisions for patients admitted to older adult psychiatric wards. This re-audit found an improvement in frequency of resuscitation decisions and also revealed differences in decision-making for patients with organic and functional disorders. Implementation of further change is indicated; decision-making can be improved through reflection, teaching, changes to practice, and technologies.

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Hsu, Grace, Jeffrey P. Gonzales, Hyunuk Seung, Mojdeh S. Heavner, Wisna Jean, and Nirav G. Shah. "Antimicrobial Therapy in Septic Shock Is Conservative During Resuscitation and Maintenance Phases." Journal of Pharmacy Technology 36, no. 4 (June 1, 2020): 119–25. http://dx.doi.org/10.1177/8755122520921516.

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Background: Maximal dosing of early antimicrobials with high loading and maintenance doses may optimize pharmacokinetic parameters to achieve and maintain therapeutic concentrations at the site of infection in septic shock. Little is known about the current practice of early antimicrobial dosing in septic shock. Objective: To characterize early antimicrobial dosing in patients in the resuscitation phase of septic shock. Methods: This retrospective cohort study included patients admitted to the medical intensive care unit (ICU) with septic shock. The primary outcome was the percentage of early antibiotic orders that were maximal or conservative during the resuscitation (0 to 48 hours) phase based on predefined dosing criteria. The secondary outcomes were the correlations of different dosing strategies on hospital length of stay (LOS), ICU LOS, and hospital mortality. Results: This study evaluated 161 patients and 692 antibiotic orders; 504 (72.8%) of the orders during the resuscitation phase were conservative. There were no differences in mortality (odds ratio = 0.66; 95% confidence interval = 0.35-1.25; P = .20), hospital LOS (median = 20 [interquartile range (IQR) = 10-34] vs 19 [IQR = 11-32] days; P = .93), or ICU LOS (median = 8 [IQR = 5-16] vs 9 [IQR = 5-15] days; P = .63) between maximal and conservative dosing groups, respectively, in the resuscitation phase. Limitations of this study included the use of institution-specific antimicrobial dosing guidelines and its retrospective nature. Conclusions: Early antibiotic dosing is conservative for a majority of patients in septic shock. Future studies are needed to evaluate the impact of dosing strategy on patient-centered outcomes in septic shock.

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Levy, Melanie. "In dubio pro CPR? The Controversial Status of ‘Do Not Resuscitate’ Imprints on the Human Body – a Swiss Innovation." European Journal of Health Law 27, no. 2 (May 14, 2020): 125–45. http://dx.doi.org/10.1163/15718093-bja10015.

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Abstract ‘Do not resuscitate’ (DNR) imprints on the human body have recently appeared in medical practice. These non-standard DNR orders (e.g., tattoos, stamps, patches) convey the patient’s refusal of resuscitation efforts should he be incapable of doing so. The article focuses on such innovative tools to express one’s end-of-life wishes. Switzerland provides a unique example, as ‘No Cardio-Pulmonary Resuscitation’ stamps and patches have been commercialised. The article discusses the challenging legal questions as to the validity of non-standard DNR orders imprinted on the human body. It analyses the obligation of healthcare providers to honour such orders, either as an advance directive or an expression of an individual’s presumed wishes, and withhold treatment. Finally, the article addresses the balancing of interests between the presumed wishes of an unconscious patient and his best interests of being resuscitated and potentially staying alive, a dilemma facing healthcare providers in a medical emergency.

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Griffith, Richard. "‘Do not attempt resuscitation’ orders: a review of the law." British Journal of Cardiac Nursing 8, no. 8 (August 2013): 404–6. http://dx.doi.org/10.12968/bjca.2013.8.8.404.

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McBrien, Michael E., and Gary Heyburn. "'Do not attempt resuscitation' orders in the peri-operative period." Anaesthesia 61, no. 7 (July 2006): 625–27. http://dx.doi.org/10.1111/j.1365-2044.2006.04702.x.

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Einav, Sharon, Alan Rubinow, Alexander Avidan, and Mayer Brezis. "General Medicine practitioners’ attitudes towards “do not attempt resuscitation” orders." Resuscitation 62, no. 2 (August 2004): 181–87. http://dx.doi.org/10.1016/j.resuscitation.2004.03.024.

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Samanta, Ash, and Jo Samanta. "Do not attempt resuscitation orders: the role of clinical governance." Clinical Governance: An International Journal 13, no. 3 (August 8, 2008): 215–20. http://dx.doi.org/10.1108/14777270810892638.

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Goh, Rudy, Stephen Bacchi, Christopher D. Ovenden, Minh-Son To, Joshua G. Kovoor, Aashray K. Gupta, Jim Jannes, and Timothy Kleinig. "Resuscitation orders demonstrate differences by gender, stroke type and intervention." Journal of Stroke and Cerebrovascular Diseases 33, no. 9 (September 2024): 107881. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2024.107881.

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Minhas, Jatinder S., Camilla Sammut-Powell, Emily Birleson, Hiren C. Patel, and Adrian R. Parry-Jones. "Are do-not-resuscitate orders associated with limitations of care beyond their intended purpose in patients with acute intracerebral haemorrhage? Analysis of the ABC-ICH study." BMJ Open Quality 10, no. 1 (February 2021): e001113. http://dx.doi.org/10.1136/bmjoq-2020-001113.

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Implementation of an acute bundle of care for intracerebral haemorrhage (ICH) was associated with a marked improvement in survival at our centre, mediated by a reduction in early (<24 hours) do-not-resuscitate (DNR) orders. The aim of this study was to identify possible mechanisms for this mediation. We retrospectively extracted additional data on resuscitation attempts and supportive care. This observational study utilised existing data collected for the Acute Bundle of Care for ICH (ABC-ICH) quality improvement project between from 2013 to 2017. The primary outcome was whether a patient received an early (<24 hours) DNR order. We used multivariable logistic regression to estimate the adjusted association between clinically meaningful factors, including an indicator for a change in treatment on the introduction of the ABC care bundle. Early DNR orders were associated with a reduced odds of escalation to critical care (OR: 0.07, 95% CI: 0.03 to 0.17, p<0.001). Commencement of palliative care within 72 hours was far more likely (OR: 8.76, 95% CI: 4.74 to 16.61, p<0.001) if an early DNR was in place. The cardiac arrest team were not called for an ICH patient before implementation but were called on five occasions overall during and after implementation. Further qualitative evaluation revealed that on only one occasion was there a cardiac or respiratory arrest with cardiopulmonary resuscitation performed. We found no significant increase in resuscitation attempts after bundle implementation but early DNR orders were associated with less admission to critical care and more early palliation. Early DNR orders are associated with less aggressive supportive care and should be judiciously used in acute ICH.

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Thomas, Shawna A., David Roggy, Natalie Fitzgerald, Kim Tosino, Dennis Magbanua, Cortni Grooms, and Allison N. Boyd. "761 Transforming Fluid Resuscitation Documentation to Improve Quality Outcomes." Journal of Burn Care & Research 45, Supplement_1 (April 17, 2024): 235–36. http://dx.doi.org/10.1093/jbcr/irae036.303.

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Abstract Introduction Accurate and readily available documentation of burn fluid resuscitation is essential for decision-making by the multidisciplinary team during the first 24 to 48 hours of care. Fluid resuscitation documentation in the electronic medical record (EMR) is ideal. However, due to the limitations of the EMR, bedside nurses must navigate to various tabs to document fluids, view orders, document events, review labs, and notify providers. To decrease burden of care and improve the accessibility of accurate fluid resuscitation information, our multidisciplinary team embarked on a journey to create a new format in the EMR for fluid resuscitation with our information technology (IT) department. Methods In April 2022, the burn team initiated discussions to build a new and streamlined process for documentation of fluid resuscitation. The goal was to decrease the amount of navigation in the EMR during fluid resuscitation by the bedside nurse and improve the accessibility of meaningful hourly documentation for the multidisciplinary team. During monthly meetings, a multidisciplinary team of nurses, a pharmacist, educators, and IT professionals collaborated on each component needed to capture the desired detailed documentation of each fluid resuscitation. Results The new format for fluid resuscitation documentation in the EMR is constructed as a navigator flowsheet and initiated in September 2023. The bedside nurse performs all documentation on this one flowsheet. Information from the Lund-Browder calculates initial fluid resuscitation rates and goal hourly urine output. Once the bedside nurse initiates the fluid resuscitation, navigating to any additional flowsheets or tabs in the EMR is unnecessary. Certain information also pulls in automatically from devices, such as vitals, bladder pressure, and urine output. Documentation of hourly fluids infused, vital signs, urinary output, fluids changes, bedside procedures performed, provider notification, nursing notes, and consulting team interventions are all performed in the narrator. The bedside nurse can also access all orders, labs, and notes without navigating elsewhere in the EMR. Real-time documentation using the narrator allows multidisciplinary team access without disrupting the patient’s nursing care. The post-resuscitation report provides hour-by-hour documentation for debriefing and reviewing each fluid resuscitation. Conclusions The development of this new tool has afforded bedside nurses more time spent caring for the patient rather than navigating the EMR. Providers no longer go to the patient room to retrieve information to help guide fluid resuscitation and disrupt patient care. The post-resuscitation report provides an accurate account of the fluid resuscitation period for debriefing and review. Applicability of Research to Practice Our process can be shared with other burn centers hoping to replicate this process.

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Haines, Ian E., John Zalcberg, and John D. Buchanan. "Not‐for‐resuscitation orders in cancer patients — principles of decision‐making." Medical Journal of Australia 153, no. 4 (August 1990): 225–29. http://dx.doi.org/10.5694/j.1326-5377.1990.tb136867.x.

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Shanmuganathan, N., J. Y. Li, T. Y. Yong, P. H. Hakendorf, D. I. Ben-Tovim, and C. H. Thompson. "Resuscitation orders and their relevance to patients' clinical status and outcomes." QJM 104, no. 6 (December 17, 2010): 485–88. http://dx.doi.org/10.1093/qjmed/hcq241.

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Thomas, Ruth H., and Martin Schuster-Bruce. "Do not attempt resuscitation orders, ethics and the Mental Capacity Act." British Journal of Hospital Medicine 72, no. 5 (May 2011): 259–63. http://dx.doi.org/10.12968/hmed.2011.72.5.259.

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Creutzfeldt, Claire J., Kyra J. Becker, Jonathan R. Weinstein, Sandeep P. Khot, Thomas O. McPharlin, Thanh G. Ton, W. T. Longstreth, and David L. Tirschwell. "Do-not-attempt-resuscitation orders and prognostic models for intraparenchymal hemorrhage*." Critical Care Medicine 39, no. 1 (January 2011): 158–62. http://dx.doi.org/10.1097/ccm.0b013e3181fb7b49.

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Ehlenbach, William J., and J. Randall Curtis. "The meaning of do-not-resuscitation orders: A need for clarity*." Critical Care Medicine 39, no. 1 (January 2011): 193–94. http://dx.doi.org/10.1097/ccm.0b013e318202e7d4.

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Loertscher, Laura, Darcy A. Reed, Michael P. Bannon, and Paul S. Mueller. "Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders: A Guide for Clinicians." American Journal of Medicine 123, no. 1 (January 2010): 4–9. http://dx.doi.org/10.1016/j.amjmed.2009.05.029.

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Zweig, S. C. "Cardiopulmonary resuscitation and do-not-resuscitate orders in the nursing home." Archives of Family Medicine 6, no. 5 (September 1, 1997): 424–29. http://dx.doi.org/10.1001/archfami.6.5.424.

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Ryden, Muriel B., Karen Brand, Eileen Weber, Heeyoung Lee Oh, and C. Gross. "Nursing home resuscitation policies and practices for residents without DNR orders." Geriatric Nursing 19, no. 6 (November 1998): 315–21. http://dx.doi.org/10.1016/s0197-4572(98)90117-3.

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Fahlstrom, Kyra, Cameron Boyle, and Mary Beth Flynn Makic. "Implementation of a Nurse-Driven Burn Resuscitation Protocol: A Quality Improvement Project." Critical Care Nurse 33, no. 1 (February 1, 2013): 25–35. http://dx.doi.org/10.4037/ccn2013385.

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Background Burn resuscitation, including titration of fluids and administration of colloids, is often driven by physicians’ orders. Inconsistencies in burn resuscitation cause overresuscitation, which has adverse consequences. Methods Retrospective chart reviews were completed to evaluate fluid resuscitation and complications for 12 months before and after development and implementation of a nurse-driven burn resuscitation protocol. Results Before implementation of the protocol, results at 24 hours after injury indicated that 58% of patients were overresuscitated, had a serum level of lactate of at least 2 mmol/L (100%), and had complications (pulmonary edema 20%, abdominal compartment syndrome 7%, acute lung injury/acute respiratory distress syndrome 30%) within the first 5 days. Two outcomes differed from before to after implementation of the protocol: serum level of lactate at 24 hours (t37.8 =2.38, P =.007) and central venous pressure at 48 hours (t31 =2.27, P =.03). After implementation of the protocol, no patients had abdominal compartment syndrome develop. Conclusions Implementation of the nurse-driven burn resuscitation protocol improved nurses’ awareness and assessment of fluid status during resuscitation and improved patients’ outcomes.

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Glasper, Alan. "Care Quality Commission slams blanket ‘do not attempt cardiopulmonary resuscitation’ decisions during the pandemic." British Journal of Healthcare Assistants 15, no. 4 (May 2, 2021): 196–200. http://dx.doi.org/10.12968/bjha.2021.15.4.196.

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Emeritus Professor Alan Glasper from the University of Southampton examines why the Care Quality Commission (CQC) has raised serious concerns relating to the use of ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders throughout the ongoing Covid-19 pandemic.

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Journal articles on the topic 'Resuscitation Orders'

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