Staff awareness of a ‘Do Not Attempt Resuscitation’ policy in a District General Hospital

Abstract

UK hospitals have been instructed to ensure that all staff understand the institution's resuscitation policy. Using a questionnaire, we determined the level of knowledge about the hospital's ‘do not attempt resuscitation’ (DNAR) policy amongst a range of staff.

Six hundred and seventy-seven questionnaires were returned. 91.4% of responders did not know the correct overall percentage survival to hospital discharge following an in-hospital cardiac arrest. 19.3% of doctors, 10.6% of nurses, and 8.9% of health care support workers (HCSW) gave answers in the correct range (i.e., 15–25%).

Most doctors (93.5%), nurses (93.5%), and HCSW (78.9%) correctly identified that cardiopulmonary resuscitation (CPR) should be the default position, when a DNAR decision does not exist. The majority of doctors (78.5%), nurses (73.2%) and HCSW (65.8%) appreciated that the hospital policy allowed a senior trainee doctor (specialist registrar; SpR) to make the initial decision without consultation with more senior medical staff. Knowledge of who was ultimately responsible for the DNAR decision was also good, with 100% of doctors, 100% of midwives, 98.3% of nurses and 78.9% of HCSW responding correctly.

Ten percent of doctors, 15% of nurses and 10.5% of HCSW believed that the next of kin could demand resuscitation or a DNAR status. There was inconsistency about what information staff felt should be included in DNAR documentation and what, if any, continuing care should be given to patients who are not for resuscitation.

Our study demonstrates that there is room for improvement in the awareness of staff about the DNAR process. The local DNAR policy is being reviewed to ensure that its messages are clear and a specific DNAR educational programme has been commenced.

Introduction

In September 2000, a number of sources reported concerns about the standards of resuscitation decision-making in the U.K. National Health Service (NHS) [1], [2], [3]. In response, the Department of Health (UK) issued a statement asking hospital Chief Executives to ensure that resuscitation policies were in place which showed respect for patients’ rights, were understood by all staff and were subject to regular audit and monitoring [4]. Specific practices, such as ageism and blanket ‘do not attempt resuscitation’ (DNAR) policies, were condemned [5]. Hospitals were instructed to use the guidance offered by the British Medical Association (BMA), Royal College of Nursing (RCN) and the Resuscitation Council (UK) (RC) [6], as the basis for developing local policy. At the same time, the Commission for Health Improvement (CHI), an organisation established to improve the quality of patient care in the NHS, was charged with ensuring that their inspection programme for hospitals includes the quality of resuscitation decision-making process [5].

Although most UK hospitals have now developed local guidance on resuscitation decisions, there has been considerable concern about how these could be audited in line with CHI requirements. The Department of Health (UK) gave no specific guidance regarding the nature of the audit to be undertaken. Possible audits might include the presence of a DNAR policy, concordance with BMA/RCN/RC recommendations, the knowledge of staff, compliance with a local policy, the quality of individual DNAR decisions, the content of DNAR records or the clinical outcome. Our Resuscitation Department decided that an audit to assess the level of knowledge of the hospital DNAR policy amongst hospital staff would be an important starting point, and one that would be fundamental to subsequent audits and educational programmes.