Jumat, 01 Juni 2012

Do not rescuscitate orders 'ignored' as doctors try to revive patients suffering cardiac arrest

Do not rescuscitate orders 'ignored' as doctors try to revive patients suffering cardiac arrest

  • One in 52 who wanted to be allowed to die had their wishes ignored
  • A third of cardiac arrests could have been prevented
  • Terminally ill patients resuscitated even though it was not in their best interests
  • Almost half of patient assessments when they reached hospital were not good enough

By Jenny Hope

PUBLISHED: 19:14 EST, 31 May 2012 | UPDATED: 02:39 EST, 1 June 2012

Doctors are ignoring ‘do not resuscitate’ orders and attempting to revive hospital patients suffering a cardiac arrest.

A report found every one of 52 patients who had made an explicit request to be allowed to die had their wishes flouted.

Other terminally ill patients were also given cardio-pulmonary resuscitation even though it was not in their best interests.

End of life care: More than a third (38 per cent) of cardiac arrests in acutely ill patients could be avoided by improving their assessment and response to deterioration, researchers finds

End of life care: More than a third (38 per cent) of cardiac arrests in acutely ill patients could be avoided by improving their assessment and response to deterioration, researchers finds (file photo)

The report investigated the care of 526 patients who had suffered a cardiac arrest in NHS hospitals in England and Wales over a two-week period in 2010, and underwent a resuscitation attempt.

In seven out of ten cases their care was ‘less than good’ with a failure to recognise warning signs that they might arrest or to contact senior doctors.

In one-third of these cases, poor care was judged to have contributed to the patient’s death, the report by the National Confidential Enquiry into Patient Outcome and Death said.

Worryingly, nine out of ten patients were never asked about their wishes should they suffer an arrest despite many having chronic disease and being at risk.

Professional and NHS guidelines recommend doctors discuss with seriously patients and their families what to do in advance, including whether to put on their records DNACPR (do not attempt CPR).

Just 122 patients had an order on their records, 70 wanted CPR and 52 did not - but they received it anyway.

In seven cases people with terminal illness were given CPR after an arrest, even though clinicians believed they would not recover from their illness and should be made comfortable in their last days.

The report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which conducts in-depth investigations of aspects of hospital care, described the case of a very elderly, acutely ill patient with severe dementia.

There was no CPR plan recorded on the patient’s notes and was dying.

When the patient went into cardiac arrest, CPR was performed for 10 minutes until a senior doctor halted the procedure - all the patient’s reviews had been carried out by juniors.

‘This was an undignified end of life that need not have happened’ said the report.

It says patients for whom CPR cann ot prolong life, but merely prolong the dying process should be identified early - fewer than 20 per cent of adult patients having a cardiac arrest in hospital will survive to discharge.

Worrying: Nine out of ten patients were never asked about their wishes should they suffer an arrest despite many having chronic disease and being at risk

Worrying: Nine out of ten patients were never asked about their wishes should they suffer an arrest despite many having chronic disease and being at risk

Report author Dr George Findlay said CPR status for each acutely ill patient should be routinely recorded on hospital notes on admission, or shortly afterwards.

NCEPOD Chairman Mr Bertie Leigh said he hoped the report would act as a wake-up call to the NHS.

He said ‘In nearly half of all the cases we reviewed there was a failure to formulate an appropriate care plan on admission, and a failure, often over several days, to find out what the patient’s wishes were - and to carry them out.

‘We are at a crossroads. All of us need to recognise and accept the limits of what can be achieved in medicine to the benefit of the patient, and a "ceiling of treatment" described and agreed with the patient wherever possible.

‘Doctors should only administer CPR where a patient has consented, or if the doctor is satisfied it is in the patient’s best interests.’

Katherine Murphy, chief executive of the Patients Association, said the report’s findings exposed a failure of communication in hospitals that would shake the trust of patients and their families.

She said ‘This report indicates that there is a huge degree of confusion about the way DNACPR orders are being handled within the NHS.

‘Patients and relatives deserve to have all of their options communicated to them in full, and then to take the decision that they feel is best for them.

Once that decision has been taken they should be able to trust clinicians to implement it.

‘Where appropriate it is also really important that relatives and carers are involved in the decision making process.

‘Instead this report shows patients that have been judged to have no chance of survival, and placed on end of life pathways, by clinicians are being given CPR anyway.  Even more worryingly, there are 52 shocking cases where patients are given CPR a DNACPR order being placed in their records.

‘The Patient Association supports NCEPOD’s call for consistent decision making and better communication. Patients need to feel they can trust the DNACPR system, and this report shakes that trust considerably.’

Dr Mark Temple, acute care fellow at the Royal College of Physicians, said many patients being considered for do not resuscitate orders are frail, elderly and have many chronic illnesses putting them at risk of a cardiac arrest, rather than as a result of heart disease.

‘In many cases CPR would be futile, damaging and have a low rate of success,’ he said.

However, even when a do not resuscitate order has been made, ther e might be circumstances which justify ignoring it, he added.

‘It may be a correct clinical judgment if the patient has made an unexpectedly good recovery, or because of an incident such as piece of toast being lodged in the throat which has nothing to do with the underlying disease,’ he said.

NHS guidelines recommend doctors discuss with seriously ill patients and their families what to do in advance, including whether to put on their records DNACPR (do not attempt CPR).

Only 122 patients had such an order, 70 wanted CPR and 52 did not â€" but they received it anyway.

Report author Dr George Findlay said CPR status for each acutely ill patient should be recorded on hospital notes on admission, or shortly afterwards.

The Patients Association said the report exposed a failure of communication that would shake the trust of patients and their families.

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