Low adherence to legislation regarding Do-Not-Attempt-Cardiopulmonary-Resuscitation orders in a Swedish University Hospital

Eva Piscator; Therese Djärv; Katarina Rakovic; Emil Boström; Sune Forsberg; Martin J Holzmann; Johan Herlitz; Katarina Göransson

doi:10.1016/j.resplu.2021.100128

Low adherence to legislation regarding Do-Not-Attempt-Cardiopulmonary-Resuscitation orders in a Swedish University Hospital

Resusc Plus. 2021 Apr 29:6:100128. doi: 10.1016/j.resplu.2021.100128. eCollection 2021 Jun.

Authors

Eva Piscator¹, Therese Djärv², Katarina Rakovic³, Emil Boström⁴, Sune Forsberg⁵, Martin J Holzmann⁶, Johan Herlitz⁷, Katarina Göransson⁶

Affiliations

¹ Department of Medicine Solna, Karolinska Institutet and Department of Emergency Medicine, Capio S:t Görans Hospital, Stockholm, Sweden.
² Department of Medicine Solna, Karolinska Institutet and Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.
³ Function of Perioperative Medicine and Intensive Care Solna, Karolinska University Hospital, Stockholm, Sweden.
⁴ Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.
⁵ Center for Resuscitation Science, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet and Department of Anaesthesiology and Intensive Care, Norrtälje Hospital, Norrtälje, Sweden.
⁶ Department of Medicine Solna, Karolinska Institutet Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.
⁷ Center of Prehospital Research, Faculty of Caring Science, Work-life and Welfare, University of Borås and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.

Abstract

Background: The ethical principles of resuscitation have been incorporated into Swedish legislation so that a decision to not attempt cardiopulmonary resuscitation (DNACPR) entails (1) consultation with patient or relatives if consultation with patient was not possible and documentation of their attitudes; (2) consultation with other licensed caregivers; (3) documentation of the grounds for the DNACPR. Our aim was to evaluate adherence to this legislation, explore the grounds for the decision and the attitudes of patients and relatives towards DNACPR orders.

Methods: We included DNACPR forms issued after admission through the emergency department at Karolinska University Hospital between 1st January and 31st October, 2015. Quantitative analysis evaluated adherence to legislation and qualitative analysis of a random sample of 20% evaluated the grounds for the decision and the attitudes.

Results: The cohort consisted of 3583 DNACPR forms. In 40% of these it was impossible to consult the patient, and relatives were consulted in 46% of these cases. For competent patients, consultation occurred in 28% and the most common attitude was to wish to refrain from resuscitation. Relatives were consulted in 26% and they mainly agreed with the decision. Grounds for the DNAR decision was most commonly severe chronic comorbidity, malignancy or multimorbidity with or without an acute condition. All requirements of the legislation were fulfilled in 10% of the cases.

Conclusion: In 90% of the cases physicians failed to fulfil all requirements in the Swedish legislation regarding DNAR orders. The decision was mostly based on chronic, severe comorbidity or multimorbidity.

Keywords: DNACPR; DNAR; Do Not Attempt Cardiopulmonary Resuscitation; Jurisprudence; Resuscitation orders; Terminal care.