Documenting DNR decisions and treatment escalation plans
In a recent BMJ Open Quality journal article*, King’s College NHS Foundation Trust (London, UK) shares its path to a more unified electronic tool to document resuscitation decisions and treatment escalation plans. Multidisciplinary teams have developed an elegant solution and are now using a more clear and consistent electronic model to guide emergency care.
A “Do Not Resuscitate” (DNR) status tells clinicians to withhold cardiopulmonary resuscitation (CPR), but what about other interventions that may be made be against the patient’s wishes or considered unnecessary? For example, actions such as giving IV antibiotics or ventilating may not make a difference to a patient’s outcomes, but they may well prolong the patient’s suffering and increase costs.
King’s College NHS Foundation Trust developed a process for clinicians to complete ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms and a more comprehensive treatment escalation plan (TEP) form to formalise consistent documentation of these important decisions for every adult patient admitted.
This project started with paper-based forms, moved to an initial electronic tool, then to Allscripts Sunrise™ electronic patient record (EPR). At each stage of the journey there was a marked improvement; Percentage of monthly admissions with documentation of CPR status increased from 18% (on paper) to 60%-70% on the first EPR and up to nearly 100% with Allscripts Sunrise.
These documents are visible in the EPR. They are accessible to care teams across the Trust. When clinical teams are debating whether or not to start antibiotics or consider moving the patient to intensive care as a patient deteriorates, for example, these documents clarify the agreed ceiling of treatment in the best interests of that patient. It’s clear, and it’s not up for negotiation.
* Johnson M, Whyte M, Loveridge R, et al. A Unified Electronic Tool for CPR and Emergency Treatment Escalation Plans Improves Communication and Early Collaborative Decision Making for Acute Hospital Admissions. BMJ Quality Improvement Reports 2017; 6:u213254.w6626. doi:10.1136/bmjquality.u213254.w6626