The impact of standardised goals of care documentation on the use of cardiopulmonary resuscitation, mechanical ventilation, and intensive care unit admissions in older patients: a retrospective observational analysis
Colette Dignam
A B * , Margaret Brown C , Chris Horwood D and Campbell H. Thompson A B
A Department of Health and Medical Sciences, University of Adelaide, Corner of George Street and North Terrace, SA 5000, Australia.
B General Medicine Department, Royal Adelaide Hospital, Port Road, Adelaide, SA 5000, Australia.
C Justice and Society, University of SA, GPO Box 2471, Adelaide, SA 5001, Australia.
D Department of Clinical Epidemiology, Flinders Medical Centre, Bedford Park, SA 5034, Australia.
Australian Health Review 46(3) 325-330 https://doi.org/10.1071/AH21321
Submitted: 6 October 2021 Accepted: 23 February 2022 Published: 5 May 2022
© 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background In South Australian hospitals, ‘Do Not Resuscitate’ orders have been replaced by ‘7-Step Pathway Acute Resuscitation Plans’, a standardised form and approach that encourages shared decision-making while providing staff with clarity about goals of care. This initiative has led to increased rates of documentation about treatment preferences, including ‘Not-For-Cardiopulmonary Resuscitation’.
Aim To quantify any effect of the 7-Step Pathway form versus previous ‘Do Not Resuscitate’ orders on cardiopulmonary resuscitation, mechanical ventilation, and/or intensive care unit admission during hospitalisation.
Methods We completed a retrospective, observational study in two Australian tertiary hospitals using interrupted time-series analysis. We examined the number of medical inpatients aged 70 years and over who received one or more Intensive Treatments-cardiopulmonary resuscitation, mechanical ventilation, or intensive care unit admission-in the 2 years before and 2 years after the introduction of the form.
Results There were 2759 Intensive Treatments across 66 051 inpatient admissions; 1304/32 489 (4.0%) pre-intervention and 1455/33 562 post-intervention (4.3%). Sub-group analysis of those who died in hospital showed 400/1669 (24%) received Intensive Treatments pre-intervention and 382/1624 post-intervention (24%). Interrupted time-series analysis suggested that the intervention did not significantly alter Intensive Treatments over time at Hospital 1 and was associated with a significant slowing of the already decreasing use of Intensive Treatments at Hospital 2. Among patients who died in hospital, there was minimal change at either site.
Conclusions There was no reduction in Intensive Treatments in older medical inpatients following the introduction of standardised goals of care documentation.
Keywords: advance care planning, do not resuscitate, end-of-life care, goals of care, health communication, intensive care unit, shared decision-making.
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