Cardiopulmonary resuscitation and endotracheal intubation decisions for adults with advance care directive and resuscitation plans in the emergency department

Abstract

Background

Emergency departments routinely offer cardiopulmonary resuscitation and endotracheal intubation to patients in resuscitative states. With increasing longevity and prevalence of chronic conditions in Australia, there has been growing need to uptake and implement advance care directives and resuscitation plans. This study investigates the frequency of the presence of advance care directives and resuscitation plans and its utilisation in cardiopulmonary and endotracheal intubation decision making.

Methods

Retrospective audit of electronic patients’ medical records aged ≥65 years presenting over a 3-month period. Data collected included demographics, triage categories, advance care directive and/or resuscitation plans/orders status.

Results

A total of 6439 patients were included representing 29% of the total patient population during the study period. Participants were randomly selected (N = 300); mean age was 78.7 (±8.1) years. An advance care directive was present in only 8% and one in three patients (37%) had a previous resuscitation plan/order. Senior consultant was present at the department for consultation by junior doctors for most of the patients (82%). Acknowledgment of either advance care directive or resuscitation plans/orders in clinical notes was only 9.5% (n = 116).

Conclusion

Advance care directive prevalence was low with resuscitation plans/orders being more common. However, clinician acknowledgement was infrequent for both.

Introduction

Advance care planning helps individuals document preferences for their future treatment for a time when they may not be able to make decisions for themselves due to cognitive impairment [1,2]. Advance care planning is recommended for all Australians aged 65 years and above or those with chronic illnesses, to express their wishes and values through an advance care directive (ACD) in relation to the level of treatment they prefer to receive from clinicians. In Australia, advance care planning is supported by both statute and common laws [3] and in the state of Victoria, there is recent legislation on Medical Treatment Planning and Decisions [4].

The Australian national general common law discusses the applicable principles to advance care planning broadly with reference to individual states and territories legal requirements [3]. There is an ongoing effort for a unified ACD [5], however Australia currently lacks a consistent national ACD [3,6,7]. While the Commonwealth could give guidance and arrange agreement on consistent legislation, under the constitution this is a state responsibility and requires State law, therefore it is the jurisdictional specific legislation on advance care planning [8] that guides clinicians on implementation at their Australian State or jurisdiction of practice.

In the State of Victoria, the level of implementation of ACD is expected to be clearly documented by treating clinicians as mentioned in Part 4, section 56 (pp. 44) of the medical treatment planning and decisions act (2016) [4] mandating the acknowledgement and adherence or non-adherence with justification to the content of ACD in clinical decision making as proven by recording in writing in individual’s clinical notes. The institutional policy on resuscitation plan (pp. 3) states, “The Resuscitation Plan should only be used to document decisions. At all times, accurate and complete notes in accordance with this policy must be maintained in the patient’s medical history” [9].

Unlike an ACD which is valid indefinitely for all healthcare facilities, a resuscitation plan which is also known as a “resuscitation order” or “goals of care” is used as a guidance on the extent of life prolonging care that can be offered. A resuscitation plan is only valid for the individual institution and is usually limited to the current admission and therefore only serves as a guide for subsequent hospital presentations.

Despite the emergence of advance care planning and resuscitation plans/orders, emergency departments (ED) continue to routinely provide emergency medical treatment (EMT) which comprises three principles; 1. Providing emergency care and interventions to acutely unwell, 2. Prevent serious damage to patients’ health, 3. Prevent patients from suffering or continuing to suffer from significant pain or distress [4,10]. In the State of Victoria, as in the rest of Australia, these principles are enshrined in the law [4].

The universal application of EMT to all ED patients may be less appropriate for the changing ED patient demographics with increasingly elderly patients [11,12] and patients living with chronic illnesses [13] of whom some are in palliative care [14]. Patients who may fall short of qualifying for EMT category but seeking treatment in ED need to be managed with treatment plans that are consistent with any pre-existing directives such as ACD or as directed by State law, in the case of Victoria, the Medical Treatment Planning and Decisions Act 2016 [1,4].

The need or consideration for EMT can be determined by utilising patients triage categories [15,16] and involving senior clinicians in treatment decision making [17]. Patients with semi or non-urgent conditions (based on their triage category) with decision-making capacity can consent or object to their care if they need to. The dilemma lies with patients who may lack decision making capacity. Clinicians then need to look for the patient’s prior wishes, such as ACD or, by consulting with surrogate decision makers, such as an appointed medical treatment decision maker [1] or the State civil and administrative tribunals, Victorian Civil and Administrative Tribunal [4] in the case of Victoria.

Previous resuscitation plans, while not considered as a valid document in determining patient treatment level, are an important element in aiding patients treatment decisions [18]. These documents are an indication of the patient’s prior wishes, as they are usually made after discussion with either a capable patient or in concordance with a surrogate decision maker, a medical treatment decision maker.

It is known that patients aged 65 years and above should have an ACD [1] or a resuscitation plan as per individual institutions policies in the absence of an ACD and depending on their presenting conditions and underlying commodities. However, the implementation of ACD has been challenging in Australia with State/jurisdictional variations and a mobile population; and that, EDs traditionally utilised and continue to utilise EMT for majority of their patients despite changing patient population dynamics and emergence of legislation's on respecting preferences through ACD in Australia.

This paper confirms other studies findings of low prevalence of ACD among the target patient population [19], and the prevalence even been lower in EDs compared to other in-patient or residential setting [20]. The paper finds that; clinicians are not reviewing ACD and previous resuscitation plans and that may result in offering futile treatment to patients leading to; unnecessary distress for the patients and their families and not re-directing resources to where it benefits most.

This study examined retrospectively, electronic records of randomly selected patients attending a level four ED [21]. The study aim was, to determine the frequency of the presence of advance care directives and resuscitation plans, written acknowledgement of the existence of advance care directive/resuscitation plans in patients’ electronic medical records, and whether cardiopulmonary resuscitation and intubation interventions offered were consistent with patients advance care directive and previous resuscitation plans.