Treatment escalation plans and DNACPR decisions within general surgery during COVID-19 pandemic

ABSTRACT

BackgroundThe COVID-19 pandemic has caused unprecedented pressures on hospital which has prompted early treatment escalation discussions. BMA guidance states that effective communication regarding DNACPRs should occur in a timely manner.1 Consideration should also be given to patients’ preferences and ample opportunity for discussions.2 However, from anecdotal evidence in an acute hospital, these conversations have not happened within general surgery. Previously, the main barriers to these discussions were having unresolved feelings around death and inadequate training.3 Many barriers to these discussions lie with doctors, we aimed to assess whether discussions were occurring, whether they were clear and accessible and to understand any barriers to discussions.MethodsCross-sectional quantitative data collection of patients admitted to an acute general surgical ward was undertaken between Nov’ 20 to March 21’. Treatment escalation and DNACPR decisions were identified from patient notes. This included time elapsed from admission, what was discussed, and by whom. A qualitative survey was sent to senior surgeons to explore ideas and any barriers to these discussions.ResultsThe study included 43 patients. 12/43 (28%) had treatment escalation discussions, with 8/12 (67%) being about DNACPR. Half of these decisions were made by ITU Outreach 4/8 (50%), none by senior surgeons. The average time elapsed from admission to a decision was 18.9 days. 35 senior surgeons were surveyed with a response rate of 14%. 4/5 (80%) thought treatment escalation options should only be discussed in patients who might deteriorate, with time pressures and fear of frightening patients as the main barriers cited.ConclusionMost patients did not have a treatment escalation plan. To address one of the main barriers identified, we have created a sticker with clear prompts for treatment escalation decisions to be placed in the clerking booklet. Further work is required to understand other barriers involved.ReferencesBritish Medical Assosciation, Resuscitation Council (UK), Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation a joint statement from the british medical association, the resuscitation council (UK) and the royal college of nursing. J Med Ethics 2001;27(5)310–6.Pitcher D, Fritz Z, Wang M, Spiller JA. Emergency care and resuscitation plans. Vol. 356, BMJ (Online). BMJ Publishing Group;2017.Chittenden EH, Clark ST, Pantilat SZ. Discussing resuscitation preferences with patients challenges and rewards. J Hosp Med 2006 Jul 1;1(4)231–40.