This is the text of the poster I’m presenting in Dublin at the European Association of Palliative Care Research Congress 9-11 June 2016. I’m hoping for lots of interaction from the other participants. But I’d love to hear your comments too
My poster suggests that limited GP knowledge of CPR survival rates surely affects DNACPR orders (Do Not Attempt CardioPulmonary Resuscitation)
Cutting to the chase, here are the conclusions
- Many GPs were signing no / only a few DNACPR forms
- Only half of GPs responsible for DNACPRs knew actual CPR survival rates for >70s and with metastatic cancer
- Under-estimates just as worrying as over-estimates
- Many of those who over-estimated were shocked by actual numbers
- Questionnaire turned into a great learning opportunity
And if you just want to move forward, here are seven ideas for that, plus some suggested resources:
- Try a CPR survival questionnaire locally – including the opportunity to share stories
- Use the excellent resources from Wales: www.talkcpr.wales
- Listen as much as – preferably more than – you talk. This especially helps those who are concerned that all doctors always want to preserve life at all costs; and also when there is limited understanding of a poor prognosis
- Always think wider than CPR. Be clear that other interventions won’t stop just because someone has a DNACPR order
- Be clear what a good Natural Death can be like: isn’t this one of those ‘everythings’ that must be done?
- Get help. Your local community geriatricians will have lots of excellent experience
- GMC advice is at:http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_CPR_cardiopulmonary_resuscitation.asp
Now I’m going to get onto some of the details …
- Following the Tracey and Winspear judgements, there are legal imperatives in England to talk to patients about DNACPR decisions – even if this doesn’t always happen (1)
- Public knowledge is limited: 50% of subjects in 2014 British survey believed CPR had at least 30% chance of successfully resuscitating a 60 yr old hospice inpatient with widespread cancer who wasn’t responding to chemotherapy (2)
- Approx half of American patients aged 60-99 who initially opted for CPR changed their mind when they learned their true probability of survival (3)
- There’s some evidence that not all hospital doctors have good knowledge of CPR survival rates (4)
- But what about primary care staff? After all, GPs are tasked with advance care planning / signing DNACPR forms
Aims: To investigate primary care staff knowledge of CPR survival rates
Method / Sample:
Forced-choice questionnaire to convenience sample of primary care staff in London, about CPR survival: out-of-hospital; in-hospital; for > 70s; with advanced metastatic cancer.
89 respondents: 50 GPs, 17 nurses, 24 others (including OTs, physios, social workers, consultants)
42 responsible for DNACPRs: 37 GPs, 5 others
For those responsible for DNACPRs: 7 (17%) had signed none. 23 (62%) had signed only 1-5 orders. 5 (12%) had signed 20+
Only 4 respondents were correct for all the survival questions
More were correct for for over 70s and patients with metastatic cancer:
23 (26%) of respondents
18 GPs: 49% of GPs responsible for DNACPRs
Many GPs responsible for DNACPRs significantly under-estimated both out-of-hospital and in-hospital CPR survival:
Out-of-hospital CPR: only 9 (21%) correct at 6-10% survival: 17 (40%) thought less 1-5%
In-hospital CPR: only 11 (26%) correct at 11-20% survival: 18 (43%) thought less 1-10%
For 34 non-GPs not responsible for signing: bigger spread of answers; with more over-estimates, especially for metastatic cancer
What do YOU recommend or want to warn against here?
- Oliver D. Resuscitation orders and reality BMJ 2016;352:i1494
- Sundar S, Do J, O’Cathail M. Misconceptions about ‘do-not-resuscitate (DNR)’ orders in the era of social media. Resuscitation. 2015;86:e3. doi: 10.1016/j.resuscitation.2014.10.014. Epub 2014 Oct 30.
- Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994 Feb 24;330(8):545-9. See also: Janssen DJ, Spruit MA, Schols JM, et al. A call for high-quality advance care planning in outpatients with severe COPD or chronic heart failure. Chest 2011;139(5):1081-8. doi: 10.1378/chest.10-1753. Epub 2010 Sep 9.
- Jones K, Garg M, Bali D, et al. The knowledge and perceptions of medical personnel relating to outcome after cardiac arrest. Resuscitation. 2006;69(2):235-9. Epub 2006 Feb 2. See also Snyder JE, Loschner AL, Kepley HO. The effect of patient age on perceived resuscitation outcomes by practitioners. N C Med J. 2010 May-Jun;71(3):199-205.