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Implementation of guidelines for No-CPR orders by a general medicine unit in a teaching hospital
1General Medicine Unit, John Hunter Hospital, Newcastle, NSW.
Background:
No-cardiopulmonary resuscitation (CPR) orders are frequently used to limit the use of cardiopulmonary resuscitation in patients who die in hospital. International research has consistently highlighted major deficiencies in the formulation, documentation and communication of such orders. There has been little Australian research into No-CPR orders and the impact of clinical guidelines.
Aims:
This audit aimed to examine compliance with published guidelines for No-CPR orders previously developed by the hospital Clinical Ethics Committee.
Methods:
The notes of all patients who died while under the care of the General Medicine Unit during June-December 1994 were reviewed to evaluate the use of No-CPR orders. Adherence to hospital No-CPR guidelines was evaluated as well as the principal diagnosis, age, level of care and competence of patients to state their wishes.
Results:
A No-CPR order was documented in 61% (n = 40) of the 66 patients who died during this period. Of these patients 80% were judged to be incompetent and were unable to be involved in decisions not to resuscitate. There was substantial compliance with the guidelines, with the exception of documenting involvement of nursing staff.
Conclusions:
No-CPR orders are frequently implemented as a result of failure to respond to curative therapy and do not represent abandonment of the patient. Although this study demonstrates the value of No-CPR guidelines and the audit process, the findings raise fundamental issues regarding the involvement of nursing staff, and of patients, that need to be further addressed.