What is actually written? Resuscitation documentation in clinical case notes:

What is actually written?
Resuscitation documentation in
clinical case notes:
ethical, legal and clinical issues
Margaret BROWN
Research Fellow, Hawke Research Institute, University of South Australia
Ravi RUBERU
Geriatric Registrar, Royal Adelaide Hospital
Campbell THOMPSON Professor of General Medicine, University of Adelaide
Harm, Health and Responsibility
AABHL 2012
Aim
To examine the nature and prevalence of
resuscitation decisions documented in in-patient
clinical notes.
Pilot Study
Selection criteria
• 70 yrs +
• Within 48 hrs of admission
• General Medicine
Method
Documentation about resuscitation decisions in
current admission
previous admissions - past 5 years
advance care plans/advance directives
Documentation was de-identified and
photocopied for qualitative analysis.
Findings
Resuscitation documentation in 34 of 99
Place of residence
Total
Home
Residential
Aged Care
Facility – low
Residential
Aged Care
Facility – high
Unknown
Total
99
78
4
16
1
With
documentation
34
22
1
11
-
20 Males
14 Females
2
(both
female)
1
-
1
-
No current
documentation
but previous
Findings
3 full resuscitation
3 no resuscitation or emergency measure
28 of 34 were for MET calls
Documentation
lacked consistency
some were difficult to read and or interpret
no consistent use of language or terms
Resuscitation discussion
The majority of decisions about resuscitation
involved a discussion with family and/or the
patient
In all but one case there was no indication about
what type of information was given to the patient or
their family or whether or not they understood the
decisions involved
Advance care directives
Advance care directives were mentioned in two
case notes but neither were available to the
medical staff
Informal advance care plans
The ‘Good Palliative Care Plan’ was available for
two current admissions and one previous
admission
One RACF ‘Palliative Care Wishes’ document was
available.
- It was dated 13/02/2006
six years previous to admission
Substitute decision makers
The reference to legally appointed substitute
decision makers was minimal
- no mention of the documents being sighted
- unclear if the EPOA or POA were valid appointments
for health care decisions
Terminology – what was actually written
The documentation relating to resuscitation
varied in every case. There seemed to be little
consistency in the terms used or the order in
which they were written.
- The only consistent documentation was
“for MET calls”
No standard list of potential treatment options
- This changed from patient to patient
- Also changes for the same patient between
admissions
Terms used
Code Blue
(mentioned in 26
cases)
• Code Blues (7)
• CODE BLUE
Acronyms
(used with or
without Code Blue)
• NFR
• CPR
• CPR + defib
• HDU
• HDV
• HV
• NIV/non-invasive
ventilation
• I+V
• ICU
• ICU admission
Terms
(used with or
without Code Blue)
• Intub/intubation
• Fibrilation
• Inotropes/any
invasive measure
• Not for aggressive/
invasive Tx
• Defib/defibrilation
Medical Emergency
Team
• MET
• MET calls
• MET calls
• MET CALLS
• METS
Terms used (cont)
Ward measures
•
•
•
•
•
•
•
•
•
•
Ward measures
Ward measure
Ward measures only
Ward medical
measure
Ward measurement
Medical ward care
Ward medical
measures
Ward management
Active ward
management
Active ward
measure(s)
Full measure(s)
•
•
•
•
Full measure(s)
Full ward measure
Full resus
Agressive/invasive
Rx
Comfort care
• Comfort care
• Comfort measures
• Conservative ward
Rx
• Only for
conservative ward
Rx
Conclusions
Clear, contemporary and accurate communication an
important part of good medical practice
Resuscitation frequently replaces the conversation
Code of conduct for Doctors 3.12 End of Life Care:
Understanding the limits of medicine in prolonging life
and recognising when efforts to prolong life may not
benefit the patient (July 2009)
Conclusion - Recommendations
Clinical Guidelines
Advance care planning
Public debate
Public Debate Recommended
“When
an
elderly
patient
of
limited
independence deteriorates and is unable to
participate in decision-making, should we
provide a palliative approach so the person can
die with respect and dignity?”
“we are all obliged to die ... If we continue to
fight all causes of mortality, particularly in
extreme old age we have no hope of success, and
we will consume an ever increasing proportion
of health care resources for ever diminishing
returns”
Iona Heath BMJ. v 341, 2010