Abstract
Introduction
Authoritative medical organisations including the Resuscitation Council UK, NHS and BMA all state that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions should only be relevant to CPR and should not impact other decisions about care and treatment. We set out to examine the reality of decision making in clinical practice.
Methods
We circulated a clinical scenario of a patient deteriorating with COVID-19 after hip fracture to 128 members of the consultant and trainee geriatrician WhatsApp groups in Wales. Recipients were blindly randomised to one of two versions; differing only in whether or not they included the words “She has a DNACPR in place”. Recipients were unaware of the survey’s purpose. We surveyed individuals’ management decisions using a multiple-choice Likert scale questionnaire.
Results
A total of 47 (37%) clinicians responded. Those who addressed the scenario without a DNACPR decision were more likely to consider non-invasive ventilation (91% vs 67%, P<0.05), and more likely to consider escalation to intensive care (26% vs 21%).
Decisions in respect of ward level care were also affected. In the absence of a DNACPR decision, clinicians were more active in providing naloxone for a potential opioid toxicity (57% vs 29%).
Conclusion
Patients’ concern that a DNACPR decision might reduce the intensity of care they might receive do not appear to be unfounded. We believe that this study demonstrates the reality of clinical decision making in acute patient care.
These clinicians will have been aware that DNACPR status should have no influence on other clinical decision making, but unconscious bias clearly has substantial influence despite this. We do not believe that training to reinforce such knowledge will ever fully compensate for such unconscious bias.
Clinicians need to consider how DNACPR decisions are made, recorded and communicated given this risk of unforeseen consequences for other aspects of care.
Comments
Fascinating.