Rethinking resuscitation: moving the goals.

Cardiopulmonary resuscitation (CPR) techniques have developed remarkably since first described. CPR is now both a default treatment and a public expectation. However, anticipated outcomes are not matched by reality. The differences between in- and out-of-hospital cardiac arrests are often not recognised and almost never taught. 'Do Not Resuscitate' orders developed to provide the ability to opt-out of this treatment. Nevertheless, CPR is still inappropriately used in settings where reversibility and likelihood of benefit are not meaningfully considered or discussed with the patient. Further, treatment escalation is a continuum, so resuscitation orders present a false dichotomy of 'do' or 'do not' resuscitate. Asking patients about their goals, and only offering treatments aligned with those goals, allows consideration of the burden of treatment and the likelihood of success. Shared decision models improve communication and patient autonomy. Tools are available to help clinicians with the difficult conversation and document the outcomes. Now, in both our training and practice, it is time to move beyond the stark and often irrelevant choice between CPR and 'Not for Resuscitation'.

Did an acute medical assessment unit improve the initial assessment and treatment of community acquired pneumonia--a retrospective audit.

AIM: Medical Assessment and Planning Units (MAPUs) are proposed as a means to treat medically unwell patients in a timely and clinically appropriate manner, thus improving quality, facilitating safe early discharge, and reducing congestion in emergency departments. This study assessed the impact of opening a MAPU on the initial assessment and treatment of patients with community-acquired pneumonia (CAP). METHOD: A retrospective audit of patients presenting to Wellington Hospital was conducted from January to March 2009 and January to March 2010, straddling the opening of a MAPU. Outcome measures included timeliness of assessment, indicators of clinical quality, length of stay, recommended follow-up and mortality. RESULTS: MAPU referred patients were less unwell and younger. Times to first doctor assessment and X-ray were longer than in the Emergency Department (ED) following the introduction of the MAPU; time to physician review for all admitted patients was unchanged compared to before the opening of the MAPU. Compliance with other aspects of evidence based guidelines was patchy and showed no improvement following the opening of the MAPU. Most patients whose length of stay was short were appropriately admitted to the MAPU. CONCLUSION: The MAPU has successfully streamed a cohort of less unwell patients away from the ED. Opportunity exists to improve the timeliness of treatment and compliance with guidelines. A disease-specific audit has served as a useful adjunct to other approaches to assessing a unit's impact.

Old man's friend? Resuscitation decisions in patients hospitalised with pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a common illness, for which hospitalisation leads to significant inpatient and subsequent mortality. The frequency and timing of discussion of end-of-life issues with these inpatients is therefore relevant. AIM: To determine whether end-of-life discussions occurred for patients with CAP whose prognostic indicators suggested a high risk of dying. METHODS: A retrospective review of 155 admissions with CAP was conducted. The nature and timing of resuscitation decisions were correlated with age, illness severity and mortality. RESULTS: Mortality following admission with CAP increases with age and severity. Of those over 65, 37% die within 12 months of discharge; 11% die on the index admission, and a further 26% die in the 12 months following discharge. Mortality increases dramatically with older age: those over 80 had a 47% 12-month mortality. End-of-life decisions were documented prior to death for all inpatient deaths. However, end-of-life decisions were only documented in a minority of other cases, even amongst those with highest risk of subsequent mortality. CONCLUSIONS: In a common illness with significant mortality, opportunity exists to better identify those at high risk of mortality and initiate discussions about end-of-life care. A not-for-resuscitation discussion currently appears to function as a surrogate marker for impending death rather than an opportunity to elicit a patient's wishes for their care should they be at high risk of dying in the near future.