Helping patients understand the risks and likely outcomes of CPR can be critical
Despite poor survival rates in the elderly following resuscitation in hospitals, not-for-resuscitation (NFR) orders are poorly understood in Australian healthcare facilities, with doctors conflating NFR orders with palliative care, research shows.
A survey of Victorian hospital doctors found 85% inaccurately believed they needed a second person’s consent, either family or staff, to write an NFR order, and that having one would and should change patient care more broadly than just in the case of arrest.
However, most states did not require consent to write an NFR order, with only Queensland requiring consent to withhold or withdraw life-sustaining measures for adults lacking capacity, the authors wrote.
“Our study showed that of the doctors we surveyed, many of them seemed to believe that an NFR order is commensurate with palliative care,” said study author Dr Amber Mills, research fellow at the Cabrini-Monash University department of medicine.
“Our point was that you can have an NFR order and not necessarily be under a palliative care approach, because an NFR order simply states if a patient arrests then don’t attempt CPR,” she said.
The prevalence of NFR orders was low in the general population, at around 12%, and about double that in people aged 80-years and older, perhaps because of the public’s overly optimistic perception of CPR success, Dr Mills said.
Previous research by Dr Mills and her team had found the majority of older patients believed they had a better than 50% chance of survival and discharge following CPR.
Yet only 11% to 15% of those up to and including 80 survive to hospital discharge following CPR, dropping to around 6% in the older population.
“When you have a cardiac or respiratory arrest in hospital, it is mandatory for staff to attempt CPR unless there’s a NFR order,” she said. “That’s why you would expect, and you should expect, that there are a lot of NFR orders written in groups for whom there are demonstrated poor outcomes.”
The study authors found that doctors were willing to write NFR orders when there was a clear medical indication and the patient was imminently dying, but otherwise were usually reliant on patients and family to initiate the discussion.
“The finding that was particularly notable for us was the impact of what we perceived to be poor knowledge of the law, particular around the issue of consent when cardiopulmonary resuscitation is likely to be futile or excessively burdensome,” she said.
GPs could assist by engaging patients in discussions around end-of-life care, and helping patients understand the real risks and likely outcomes of CPR treatment, Dr Mills said.
“If patients had a more accurate view about what the likely outcomes of hospital CPR were, especially for older patient, then they may be more likely to raise the topic of an NFR with the treating doctor in hospital,” she said.
“We need to educate and encourage patients to verbalise what they would like,” she said.
While discussion with the patient and family was important, ultimately ordering an NFR was a medical decision on whether resuscitation was considered to be futile and/or burdensome treatment.
Aust Health Rev 2016; online 25 November
