Do not resuscitate orders in the time of COVID-19: Exploring media representations and implications for public and professional understandings

Context:: During the COVID-19 pandemic, the UK press featured headlines that heightened concerns around Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, particularly the use of 'blanket' DNACPR orders applied to older people in care settings. The portrayal of DNACPR may impact professional and public understandings with implications for end-of-life care. Objectives:: To explore the portrayal of DNACPR orders in the general and academic press and consider implications for public and professional understandings and practice. Method:: Academic papers and articles published in the general press during the first wave of the COVID-19 pandemic in the UK were retrieved. Those pertaining to the use of DNACPR orders were analysed thematically. Results:: Analysis of 179 media articles and 11 professional commentaries identified mixed understandings of DNACPR as indicated within three themes: rationing of acute services, championing autonomy in DNACPR decisions, and communication and trust. The call to 'protect the NHS' marginalised palliative and social care services with DNACPR constructed as a rationing tool. This led to ethical challenges around autonomy, DNACPR decisions, communication and trust. Conclusions:: Media coverage of DNACPR orders was contentious and raised questions around the value of life and quality of dying, particularly for vulnerable individuals. DNACPR orders were conflated with frailty, futility and rationing of acute services and the marginalisation of palliative care. Nevertheless, media outputs stimulated advocacy and support for human rights and autonomy. However, it is unclear what the legacy will be for public and professional understandings of advance care planning and the quality of dying.

Early Versus Late DNR Orders and its Predictors in a Saudi Arabian ICU: A Descriptive Study.

Background: Practices of Do-Not-Resuscitate (DNR) orders show discrepancies worldwide, but there are only few such studies from Saudi Arabia. Objective: To describe the practice of DNR orders in a Saudi Arabian tertiary care ICU. Methods: This retrospective study included all patients who died with a DNR order at the ICU of King Saud Medical City, Riyadh, Saudi Arabia, between January 1 to December 31, 2021. The percentage of early DNR (i.e., ≤48 hours of ICU admission) and late DNR (>48 hours) orders were determined and the variables between the two groups were compared. The determinants of late DNR were also investigated. Results: A total of 723 cases met the inclusion criteria, representing 14.9% of all ICU discharges and 63% of all ICU deaths during the study period. The late DNR group comprised the majority of the cases (78.3%), and included significantly more patients with acute respiratory distress syndrome (ARDS), community acquired pneumonia (CAP), acute kidney injury, and COVID-19, and significantly fewer cases of readmissions and malignancies. Septic shock lowered the odds of a late DNR (OR = 0.4, 95% CI: 0.2-0.9;P= 0.02), while ARDS (OR = 3.3, 95% CI: 2-5.4;P < 0.001), ischemic stroke (OR = 2.5, 95% CI: 1.1-5.4;P= 0.02), and CAP (OR = 2, 95% CI: 1.3-3.1;P= 0.003) increased the odds of a late DNR. Conclusion: There was a higher frequency of late DNR orders in our study compared to those reported in several studies worldwide. Cases with potential for a favorable outcome were more likely to have a late DNR order, while those with expected poorer outcomes were more likely to have an early DNR order. The discrepancies highlight the need for clearer guidelines to achieve consistency.

Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe.

BACKGROUND: Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe. OBJECTIVES: The purpose of this post-hoc analysis of the prospective multicentre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic. METHODS: A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aORs) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (gross domestic product, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day mortality was a secondary outcome. RESULTS: The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%) and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95% confidence interval [CI] 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78). CONCLUSION: This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results.

[Ethics, communication and interdisciplinary collaboration-by law?!] / Ethik, Kommunikation und interdisziplinäre Zusammenarbeit ­ per Gesetz?!

CONTEXT: The coronavirus pandemic of recent months has highlighted the fact that death is still a taboo regardless of the progress that has been made in palliative care. The concept of advance care planning is still not adequately practiced by individuals yet and we do not know enough about what is important for people in the last phase of their lives. CONCLUSIONS: Nurses can play an important in discussions about values and the ideas of what is important when death is getting closer. In Germany, there is a law (§ 132g Abs. 3 Sozialgesetzbuch V) that makes it possible to receive remuneration for these conversations. Hopefully, this is just the first of many steps to further develop ethics, communication and interdisciplinary collaboration.

Comparison of clinicians' perceptions of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) before and during the COVID-19 pandemic.

INTRODUCTION: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process encourages collaboration between clinicians, patients, and relatives on emergency care wishes and resuscitation decisions. The impact of the COVID-19 pandemic on clinicians' views of the ReSPECT process was unknown. We examined whether there were changes in clinicians' knowledge, skills, and attitudes regarding ReSPECT during the pandemic. METHODS: We conducted a cross-sectional survey of clinicians at one acute hospital in the UK. We developed a questionnaire with a defined 5-point Likert scale and asked clinicians to recall their pre-pandemic views on ReSPECT and report their current views at the time of survey distribution (May 2020, end of the first COVID-19 wave in the UK). We compared their self-reported views before and during the pandemic. RESULTS: We analysed 171 questionnaire responses. Clinicians reported ReSPECT telephone discussions with relatives were more challenging (pre-pandemic median 4, IQR 3-4; during pandemic median 4, IQR 4-5; p < 0.001) and negative emotions whilst conducting these discussions with relatives increased during the pandemic (pre-pandemic median 3, IQR 2-3.5; during pandemic median 3, IQR 2-4; p < 0.001). Clinicians also reported an increase in the importance of reaching a shared understanding of decisions with patients and relatives (pre-pandemic median 4, IQR 4-5; during pandemic median 5, IQR 4-5; p < 0.001). CONCLUSIONS: There were differences in clinicians' knowledge, skills, and attitudes scores before and during the pandemic. Our findings highlighted that clinicians could benefit from training in remote ReSPECT conversations with relatives.

The Effect of Triggered Palliative Medicine Consults on Nurse Moral Distress in the Medical Intensive Care Unit.

PURPOSE: Moral distress in the intensive care unit contributes to negative emotional experiences in nurses and adversely affects patient care. This prospective cohort study evaluates an intervention designed to improve nurse moral distress in the medical intensive care unit and assesses patient outcomes which may improve moral distress. METHODS: Nurse moral distress was measured before and after an intervention of triggered palliative consults and scheduled family meetings in the intensive care unit during the COVID-19 pandemic. Patient outcomes in the intervention medical intensive care unit were compared to a control group. RESULTS: Forty-eight nurses (n = 48/78, 62%) completed the pre-intervention survey and 33 (n = 33/78, 42%) completed the post-intervention survey. Nurse moral distress using the MMD-HP scale pre- and post-intervention (122.5 vs. 134.0, P = 0.1210) was not statistically different. Intervention group patients (n = 57/64, 89%) had earlier transition to do not resuscitate status (hazard ratio 2.1, 95% CI 1.1-4.0, P = 0.0294), higher rate of documented alternate decision makers (100% vs. 61%, P < 0.0001), and higher rate discharged to a facility (28% vs. 14%) or hospice (19% vs. 7%) (P = 0.0090). Intervention group patients with a do not resuscitate (DNR) order had lower median length of stay in the intensive care unit (4 days vs. 13 days, P = 0.0004) and hospital (10 days vs. 21 days, P = 0.0005), and lower median total hospital costs per patient ($39,067 vs. $116,476, P = 0.0029) when compared control group patients with a DNR order. CONCLUSION: Triggered palliative consults with scheduled family meetings were not associated with change in nurse moral distress. More research is needed to uncover methods to improve nurse moral distress in the intensive care unit.

Early resuscitation orders in hospitalized oldest-old with COVID-19: A multicenter cohort study.

BACKGROUND: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is essential to assist patient autonomy and prevent non-beneficial medical interventions. AIM: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19. SETTING/PARTICIPANTS: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians. RESULTS: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in 474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty (p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1% in persons who developed respiratory failure vs 16.7% in patients without respiratory failure (p < 0.001)). Of 104 patients without early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%. CONCLUSIONS: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of conservative treatment.

Documentation of Do-Not-Attempt-Cardiopulmonary-Resuscitation orders amid the COVID-19 pandemic.

INTRODUCTION: the COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation (CPR) into focus. The aim of this study is to compare rates of Do-Not-Attempt-CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. METHODS: this was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from 1 March to 31 May 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period and were also compared to the documentation rates pre-COVID-19 pandemic (1 March-31 May 2019). RESULTS: of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. Of 131 older (≥65 years) patients with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 older patients without COVID-19 (P < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (P < 0.0001). Almost fifty percent of DNACPR orders were recorded within 24 h of a positive swab result for SARS-CoV-2. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived. CONCLUSION: the COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case fatality rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain as part of good clinical practice despite the pandemic.