This audit was done to interrogate the current practice regarding advance resuscitation decisions in the public hospital setting in Sri Lanka, with a view to explore the measures that can improve this practice. The comparison of results between the pre- intervention and post- intervention groups clearly demonstrates that simple measures like improving the knowledge of junior doctors about advance resuscitation decisions and introduction of a pre-printed form to document these decisions can significantly improve patient outcomes in end-of-life care.
The baseline characteristics of the two patient groups on presentation to the hospital are not very (Table 1) different from each other. As highlighted above, the fact that none of the patients in either group had a prior resuscitation decision (carried over from previous admissions/ encounters with health care professionals) or an advance health directive on admission reflects the lack of knowledge about such decisions among both the public as well as health care professionals treating them. The situation is made worse by lack of specific laws to empower advance health directives or to appoint guardians for health-related matters when people lack capacity.
Increase in the number of documented DNACPR decisions in the post- intervention group compared to the pre- intervention group must have been driven by several factors.
-
Improved knowledge in junior doctors within the team
-
Increased consciousness about the concept in senior doctors with an adequate knowledge
-
Better documentation of the decisions taken
In our experience, it is a common misconception among junior doctors that all patients with cardio-respiratory arrest should be resuscitated as a legal requirement.
Many patients were unsuccessfully resuscitated before their death. The number of unsuccessful CPR attempts reduced significantly in the post- intervention period compared to the pre- intervention period. The unsuccessful resuscitations which happened even when there was a clearly documented decision not to resuscitate reflects a failure in communication between the doctors. This could have happened for several reasons.
-
Incomplete shift handovers
-
Not respecting documented decisions
-
Not reading previous entries in patient notes
-
Not understanding the documented concept
-
Pressure from patient’s family to do ‘everything’
In the pre-intervention period, all the documented DNACPR decisions have been initiated by the consultants. This is a positive approach as the team leader. In contrast, most of the decisions in the post- intervention period have been taken by the senior Registrars and later approved by the consultants. This could be thought as a more encouraging approach to inculcate the concept among trainees. There is one decision that has not been approved by the consultant. Such moves could contribute to poor patient outcomes and trainees should always discuss these decisions with the most senior and the most experienced member of the treating team.
Involvement of the family without the patient even when the patient has capacity to make decisions is seen in both pre- and post- intervention groups. On the one hand, this reflects the doctors’ acceptance of the concept of ‘familial dominance’ seen in Asian culture, but on the other hand their failure to respect patient autonomy(12)(10).
We identified that documentation is suboptimal regarding clinical decisions at multiple stages of process. Introduction of a standardized goals-of-care form has most probably contributed to the improved documentation in the post-intervention group in combination with other measures. Medical practitioners should be encouraged properly document their clinical decisions for the safety of both the patients and medical profession.
Furthermore, we noticed that many of the patients who received a DNACPR decision had an ICU admission. While this shows prudent decision making in a critical care setting, it may again reflect failure of early decision making. Some patients had been appropriately stepped down from the ICU to a more palliative treatment approach when further escalation of care was decided not to be in the best interest of the patient.
Considering the above findings of suboptimal practice and documentation of advance resuscitation decision, we can conclude that the lack of legal actions taken against resuscitation practice, is probably a reflection of failure of the system rather than perfect clinical practice. The possible reasons for this failure are,
-
Lack of public knowledge about such procedures
-
Legal procedures consume a lot of money and time
-
Public respect towards doctors as authoritative figures
-
Corruption and malpractices in the legal system itself
There are several limitations in this audit. Firstly, although we assessed the number of co-morbidities on presentation, we did not assess the severity/acuity of the presenting disease/ condition, which has a huge impact on the resuscitation decision as well as escalation of patient care (Eg; APACHE, SAPS, SOFA, MODS)(13)(14). Secondly, the audit was limited to two general medical wards in the National Hospital of Sri Lanka, which is the main tertiary care reference center in the country. Therefore, the results cannot be generalized to other settings of care. Thirdly, the follow up was limited to two months, which is inadequate to assess sustainability of our interventions.
For the future, we suggest that Sri Lanka needs more larger scale clinical audits to find out existing practice about end-of-life care across all tiers of health care. More interventional studies are required to experiment the appropriate treatments and more effective methods to improve documentation of clinical decisions (Eg; to evaluate the performance of a standardized form to document resuscitation decisions at national level) in end-of-life care.
Within the constraints of our audit, we recommend that precise documentation of clinical decisions is paramount to success in end-of-life care. Importantly, when a decision is made, this should be reviewed regularly during the index admission and during subsequent admissions. The legal framework regarding resuscitation decisions should be revisited and revised. Appropriate measures should be taken to increase public awareness about the appropriate use of CPR and other measures of escalation of care. Patients/ public should be encouraged to make their own resuscitation decisions well in advance of a crisis and there should be appropriate legal provisions to ensure the legal validity and safety of an advance resuscitation plan thus established. Teaching about end-of-life care should be a mandatory component both undergraduate and postgraduate education of doctors. We also propose that doctors should have ongoing training regarding the importance of medical documentation to improve patient outcomes as well as for the safety of the profession against litigation.