The role of audit in making do not resuscitate decisions

Introduction

Cardiopulmonary resuscitation (CPR) as we know it

today originated in 1960. Resuscitation of the dead

has been attempted since early biblical times, but it

was only adopted formally after Kouwenhoven's new

technique of closed-chest cardiac massage and

mouth-to-mouth ventilation was described

(Kouwenhoven et al. 1960). CPR was initially used

for those patients with a sudden primary cardiac or

respiratory arrest, but who had been previously

healthy. In this group outcome was impressive, with

60±70% surviving to leave hospital. However, it soon

became common practice to attempt resuscitation on

any hospital patient who suffered a cardiac arrest,

even those in whom there were multiple chronic ill-

nesses or where cardiac arrest was a secondary event

occurring in the presence, for example, of pneumo-

nia, cardiac failure or cancer. Not surprisingly out-

come in this group was much worse. Some patients

were initially resuscitated, but subsequently died

after a few days. Others survived, but failed to make

a full recovery because of neurological damage sus-

tained during the resuscitation attempt (Bedell et al.

1983, Blackhall 1987; Tomlinson & Brody 1988). It

became apparent that patients rarely survived if they

had multiple chronic illnesses, if there had been a

gradually deteriorating clinical course or if the car-

diac arrest occurred in the presence of infection,

especially bronchopneumonia. Some patients, such

as those with disseminated cancer, severe cardiac or

renal failure or severe hypotension, rarely survived

(Blackhall 1987; Tomlinson & Brody 1988).

It soon became clear that if all hospital patients

were to be considered potential candidates for CPR,

then there would be situations when this would be

inappropriate. Therefore, in these patients a decision

would need to be made in advance so that resusci-

tation would not be attempted in the event of a

cardiac arrest. This concept resulted in the `Do Not

Resuscitate (or DNR) order'.

The DNR order

The DNR order is a statement of a decision that a

particular patient should not be resuscitated if they

were to suffer a cardiac arrest. If a DNR order is not

made then, in most acute hospitals, patients will have

a resuscitation attempt. In the United States the use

of DNR orders has been governed by legislation

The role of audit in making do not resuscitate decisions

Suzanne Hayes MRCP1 and Kevin Stewart FRCP2

1Royal Hampshire County Hospital, Winchester, Hants, UK2Whittington Hospital, Highgate Hill, London, UK

Correspondence

Dr K. Stewart

Consultant Physician

Royal Hampshire County Hospital

Romsey Road

Winchester

Hants SO22 5DG

UK

Keywords: audit, resuscitation

Accepted for publication:

14 December 1998

Abstract

Audit has been proposed as a useful means of implementing and evaluating

`Do Not Resuscitate (DNR)' policies. This paper explores the background

to the introduction of DNR policies and reviews published reports of their

use in clinical practice. Problems with auditing and implementing DNR

policies are highlighted.

Journal of Evaluation in Clinical Practice, 5, 3, 305±312

# 1999 Blackwell Science 305

since the 1970s. There are strict rules about who

should be consulted and the format which any doc-

umentation concerning the DNR order should take

(Florin 1993).

In general, there has been little enthusiasm for

adopting this strict legal approach in the UK. Many

British physicians would perhaps regard medical

practice in the United States as being too tightly

governed by legal considerations resulting in some

treatments which are of dubious clinical value

being used too much in patient care. (Currie 1988).

As recently as 1982 an editorial in the British Medi-

cal Journal called for a less formal approach to

`end of life' decision making because British

patients were thought more likely to trust their

doctor to decide on their behalf (Bayliss 1982).

This view needed re-evaluation in 1991 with the

publication of the Annual Report of the Health

Service Commissioner (or Ombudsman). A formal

investigation was conducted into a complaint from

a patient's son about a DNR order which had been

made on his elderly mother. During the course of

this investigation the Commissioner realized that

there was no nationally agreed policy for making

DNR decisions. These decisions appeared to be

made mainly by junior doctors, often without a

facility for automatic review by senior colleagues.

Decisions were sometimes documented, but some-

times simply given verbally. It was common prac-

tice for codes, rather than clear English, to be used

in documentation (e.g. `not for 222', the emergency

cardiac telephone number) and it was unusual for

the reasons for exclusion from resuscitation to be

documented. There seemed to be no agreed policy

on when, or if, it was appropriate to discuss resusci-

tation decisions with patients or their relatives. In

the report, the Commissioner expressed particular

concern that written policies on such an important

area seemed to be regarded by hospitals as `some-

thing of a novelty' (Saunders 1992).

As a result the UK Government's Chief Medical

Officer (CMO) wrote to all doctors in England and

Wales highlighting the Health Service Commissio-

ner's concerns and suggesting that it was an appro-

priate time for the medical profession to formalize

practice in this area (Calman 1991). He suggested

that the Government was looking to the medical

profession to provide a lead by drawing up formal

guidelines for clinical practice, which could then be

audited (Gillon 1992).

Subsequent to this CMO letter several sets of

guidelines were produced. The most widely accepted

of these was from the British Medical Association

(BMA) drawn up in conjunction with the Royal

College of Nursing (RCN) and the Resuscitation

Council, but others were produced by the Royal

College of Physicians of London (RCPL) and by

Doyal and Wilsher, two ethicists at a London Med-

ical School (British Medical Association & the Royal

College of Nursing 1993, Doyal & Wilsher 1993;

Williams 1993).

Principles and recommended procedure for making

DNR orders

The three main sets of guidelines agree on the prin-

ciples behind DNR orders and the procedures for

making them. They all suggest that:

The consultant in charge of a patient is ultimately

responsible for making the DNR decision and should

arrange to review any decisions made by junior

doctors. The consultant should also ensure that his/

her junior doctors are aware of the current DNR

policy and understand that these decisions must be

discussed with other staff as appropriate.

1 DNR decisions should be clearly documented in

both medical and nursing notes (without using codes

or abbreviations) and the reasons behind the DNR

decision documented.

2 DNR decisions should be reviewed regularly.

3 DNR decisions should be made if:

. the patient's clinical condition indicates that CPR

is very unlikely to succeed (i.e. it would be futile)

. a competent, fully informed patient decides in

advance that they do not wish to have CPR

attempts, should they suffer a cardiac arrest

. the patient's view of the quality of their life is that

it is so poor that they would not want life

prolonging measures.

Guidance on when to discuss resuscitation with

patients and relatives is less clear because there is

concern that patients may be distressed by such dis-

cussions. There is, however, a general consensus that

discussion with patients is likely to be beneficial if

decisions are made on quality of life issues as the

physician must consider the patient's view. If DNR

S. Hayes and K. Stewart

# 1999 Blackwell Science, Journal of Evaluation in Clinical Practice, 5, 3, 305±312306

decisions are made on the grounds of medical futility,

discussion with the patient is thought to be of less

value (Florin 1994).

DNR orders in the United States (US)

DNR orders have been widely discussed in the US in

both the medical and public press for a number of

years and most US hospitals have formal DNR

policies. There are important differences between

the US and the UK concerning DNR orders. Typi-

cally in the USA, the order must have the patient's or

a designated surrogate's consent as a written record.

The American health profession is therefore pursu-

ing a very formal approach to the use of DNR orders,

which may well be because doctors in the US face a

high level of litigation and so feel that they are pro-

tected professionally if this difficult area is embodied

in the Law. However, the introduction of legislation

has not been without problems (Florin 1993).

Difficult areas in the study of implementation of

DNR orders have focused, in particular, on the role

of the surrogate (i.e. a friend or family member who

makes decisions on behalf of the patient if the patient

is incapacitated). The patient or their surrogate may

disagree with a DNR decision even if the physician

considers CPR to be futile. The surrogate may not be

aware of the patient's true wishes or even that the

patient had designated them as a surrogate. Inter-

estingly in one study, physicians still ranked lack of

discussion between doctor and patient as an impor-

tant obstacle in issuing a DNR order (Cammer-Paris

et al. 1993). So despite wide coverage by the Amer-

ican medical and lay press about end-of-life issues

and implementation of formal policies in most hos-

pitals and state legislation, DNR decisions remain an

emotive area, which can cause conflict between

doctors and their patients. In fact, in New York State,

rather than clarifying the issue, legislation seems to

have raised more points for contention and despite

recommendations from many leading American

physicians to amend it, the law remains unchanged

(Waisel & Truog 1995).

Outcome of CPR

When considering a DNR order for a patient the

physician involved should have a knowledge of the

outcome of CPR, so that they can make an appro-

priate decision and so that they are able to give the

patient the full, accurate information necessary to

make an informed decision. The most common out-

come measure for CPR is generally taken as survival

to discharge. In the BRESUS study, for example,

only 17% of patients survived to discharge from

hospital, with 72% of those living a further year.

Overall, most studies indicate that 10±20% of

patients survive to discharge following CPR

depending on selection (Bedell 1983; Tunstall-Pedoe

et al. 1983, Hanson 1984; Taffet et al. 1988; Warner &

Sharma 1994).

However, outcome is not solely dependent on

premorbid factors. Intra-arrest factors, such as the

initial heart rhythm have been considered to be

important predictors of survival. Those patients with

ventricular fibrillation (VF) or bradycardia have a

significantly better clinical outcome. Length of

resuscitation attempt is also a good predictor of

survival to discharge, in that those patients who have

CPR for a shorter time are more likely to survive. In

the light of the many variables that influence the

outcome of CPR, it is not surprising that doctors find

it difficult to make a DNR decision (George et al.

1989, MacIntrye 1993, Rosenberg et al. 1993; Wenger

et al. 1995).

Audit and DNR orders

Since the introduction of DNR orders, there have

been a number of surveys looking at their imple-

mentation in hospitals, some of which use clinical

audit methods.

Keatinge (1989) assessed the factors which deter-

mined the exclusion of patients from resuscitation in

a London teaching hospital. He performed a retro-

spective casenote study of all those patients who died

in a one-year period from April 1986±87. There were

156 resuscitation attempts in the study period; 17

patients (10.9%) survived to leave hospital. Using a

multifactorial analysis certain factors were sig-

nificantly associated with exclusion from CPR,

including a past history of dementia, incurable

malignancy, pneumonia or stroke. Conversely, a

history of hypertension, male sex, a high level of

activity at home before admission and a cardiac

arrest in the intensive care unit or operating theatres

# 1999 Blackwell Science, Journal of Evaluation in Clinical Practice, 5, 3, 305±312 307

The role of audit in DNR decisions

was significantly associated with a resuscitation

attempt. Nevertheless CPR was still attempted on 21

patients with incurable malignancy, none of whom

survived to discharge. Analysis of the data also

showed that the only pre-arrest factor associated

with survival to discharge was degree of activity pre-

admission. This study recommended further collec-

tion of data of patient characteristics related to out-

come, but did not in itself complete the `audit loop'.

Aarons & Beeching (1991) examined the use of

DNR orders in a district general hospital (DGH) in

Liverpool by a point prevalence questionnaire sur-

vey. A questionnaire was sent to all the acute medical

and surgical wards to be filled in for each current

inpatient by the nurse in charge and a junior doctor

looking after the patient. Information on 297

(93.7%) inpatients was analysed. Doctors thought

CPR was inappropriate for 88 (29.6%) of the total,

for four (3.8%) of the surgical patients, 25 (92.6%) of

bedridden patients and 12 (92.3%) of patients with

poor cognitive function. Interestingly, 34 (69.4%)

patients with cancer were thought to be suitable

candidates for resuscitation. Documentation of the

DNR orders was poor as only 24 (27.3%) of the

patients thought to be unsuitable for resuscitation

had a DNR order documented in the medical notes

and two patients thought suitable for CPR had a

DNR order in the notes. Out of the 26 DNR orders

the contents of 21 were available, of which 20 were

written in medical jargon or abbreviations. In the 26

patients with a DNR order in the medical notes, only

10 (38.5%) had a similar record in the nursing notes.

In answer to the question `Would you call a crash

team if this patient had an arrest?', an arrest team

would have been called for 24 patients who were

thought to be unsuitable for CPR by both doctor and

nurse. Discussions about prognosis were known to

have taken place with relatives of 69 out of 203

(34%) patients, but these were recorded in only 31

(44.9%) cases. For those patients thought to be

unsuitable for a CPR attempt, prognosis had been

discussed in only 32 (36.4%) cases. There is no par-

ticular mention of discussion with the patient them-

selves. This questionnaire study highlights the

inconsistencies in DNR decisions at ward level and

therefore the need for a more formal approach, but it

does not go on to amend current practices and per-

form further audits.

Stewart et al. (1994) used audit to introduce a

formal DNR policy in a DGH in London, UK. Staff

knowledge (medical and nursing) of the current

resuscitation policy was assessed by a written ques-

tionnaire (total 210) and an inpatient casenote survey

was performed (total 351 patients). The initial survey

demonstrated no fixed policy and conflicting infor-

mation between nursing and medical notes. A DNR

order was recorded in the medical and/or nursing

notes in 67 (19%) cases, but the reason for exclusion

from CPR was recorded in only 39 cases (58%). In

one case there was a specific record for resuscitation

in the medical notes, but DNR was recorded in the

nursing notes. Sixteen patients who had incurable

malignancy did not have DNR orders. The staff

questionnaire revealed that 50 (42%) of the total

responders (120) were unaware of a DNR policy.

Almost all stated that there was no formal method

for regular review of DNR orders (118 out of 120). A

standard was then introduced by which every patient

admitted to given wards had a DNR audit form

completed on admission which included:

. a provisional resuscitation status as decided by

the admitting doctor

. a review of this decision within 48 h by, or after

discussion with, the consultant

. if the consultant's decision was `DNR', the reason

for this

. documentation of communication with nursing

staff.

The practice was reviewed over a three month

period during which 712 patients were admitted.

Information was available for 309 (43%) cases, of

which only 142 admission resuscitation decisions

were reviewed by a consultant. Junior staff made a

DNR order in 60 (19%) patients on admission. There

was a consultant review in 34 (57%) cases, confirm-

ing DNR in 31 cases. In 25 cases the decision had not

been reviewed by the consultant by the patient's

death or discharge. 249 patients were marked `for

resuscitation' on admission and this was reviewed in

108 (43%) cases, of which 24 decisions were changed

to DNR. Consultant review of the DNR decision was

carried out in 48 h for 87% of cases. Reasons behind

the DNR decision were documented in all 55 cases

and in 49 cases communication with the nursing staff

was recorded.

Hignett et al. (1996) reported an audit carried out



over three years which aimed to improve the

appropriateness and documentation of DNR orders

in an elderly care ward in a university teaching hos-

pital in the UK. A retrospective casenote study of all

resuscitation attempts in the Department for Elderly

Medicine was performed. Fourteen cases were

identified of which 13 sets of notes were available.

CPR was judged to be appropriate in 6 (46%) out of

the 13 cases. A standard was set in a similar manner

to that of Stewart et al.:

. resuscitation status of each patient should be

decided by a senior member of the medical team

after discussion with nursing staff and sometimes

with the patient and their relatives

. there was to be regular review of resuscitation

status

. resuscitation status should be documented.

Follow up audits were carried out annually for two

years. In the first there were 20 CPR attempts in the

unit of which 19 casenotes were available. Resusci-

tation status was not recorded in any of the medical

or nursing notes. Ten (53%) cases were thought to

have been appropriate for CPR attempts. Four of the

arrests occurred soon after admission, so the audit

guidelines were amended in that resuscitation status

should be made by a junior doctor in discussion with

a senior nurse within 24 h of admission. In the final

audit there were 23 CPR attempts, with information

available for 21 cases. Documentation of resuscita-

tion was available for 15 (71%) cases. CPR was felt

to be appropriate in 11 (52%) of cases. The authors

felt that their audit had improved the documentation

of resuscitation status of patients in their unit, but the

numbers are too small for statistical analysis. The

audit involved senior nursing staff and found that

there was a high correlation between the nurses

views of appropriateness of CPR and a consultant

geriatrician, but again only for a small number of

cases. Another important limitation of this audit is

that it was restricted to patients in the elderly care

unit only.

In New Zealand, Taylor et al. (1996) described the

introduction of a DNR policy in a university teaching

hospital. They first devized a policy with input from

medical, nursing and ethical representatives, which

allowed two distinct methods for making a DNR

order. Firstly, a patient could make an informed

decision which was documented and witnessed.

Secondly, a DNR order could be made on clinical

grounds if CPR was deemed not to be beneficial to

the patient by medical and nursing staff. Integral to

the policy was an attempt to discuss the issue with the

patient and sometimes their relatives. Importantly

there was a change in the hospital information pack

to include explanation of the DNR issue and

instructions to patients if they wished to consider this

as an option in their care. There was a trial period of

14 weeks, during which 1023 patients were admitted

to the medical wards (52 deaths) and 1348 to the

surgical wards (13 deaths). In 54 (86%) of the deaths

there was a DNR order, but only 14 (26%) of these

were in the format of the hospital approved policy. A

total of 28 patients had DNR decisions made in the

recommended format and of these 14 died and 14

survived to discharge. Discussion with patients and

their relatives was more frequent for those with

DNR orders made in accordance with the trial pro-

tocol, but this was not statistically significant. A

nurse was present in only 50% of discussions and

none were qualified for more than 3 years, despite

this being a requirement in the DNR policy. As in the

other studies discussed, a staff questionnaire was

used to assess the level of knowledge about DNR, of

which 75 (48%) were returned. 99% were aware of

the trial, but it had been previously publicized and

61% had read the DNR policy document. 97%

agreed that a DNR policy was needed, but only 44%

thought that the current trial fulfilled this, because

the policy document was complex and there

remained a general reluctance amongst medical staff

to discuss this issue. 51% thought that the strict

requirement of particular team members to be

present when making a DNR decision was difficult in

practice. Only 18% of respondents understood the

term `mentally incompetent' and 45% wrongly

thought that the next of kin, not the medical team,

had ultimate responsibility for the DNR decision if a

patient was incapacitated. This study is a survey and

not a true audit, but it raises a number of important

points: DNR policies can be difficult to implement

and are often complex to understand. The knowledge

of medical and nursing staff about DNR and other

ethical areas such as `competence' is poor.

In the US, Wenger et al. (1995a) has attempted to

characterize which patients receive DNR orders and

their outcome. Although the research is descriptive, it



is still useful. In a retrospective review of 14 000

patients it was found that 11% of patients had DNR

orders. Even in critically ill patients only 31% were

assigned DNR orders and, significantly, they were

given to patients who were older, female, suffered

from dementia or were incontinent. Another US study

of patients aged over 65 years with one of five dis-

orders (congestive cardiac failure, pneumonia, acute

myocardial infarction, CVA or hip fracture) examined

the outcome of patients with a DNR order vs. patients

who were `for CPR'. As expected, those patients with

a DNR order had a significantly higher inpatient

mortality. Timing of the DNR order appeared to be

associated with mortality. Patients with an early DNR

order were more likely to survive to discharge than

those patients with a late DNR decision. Wenger

suggests that the DNR order may represent a marker

of deterioration in the patient's condition. On the

figures presented there is no proof for this, but it does

highlight the point that a patient's clinical condition is

continually changing and therefore CPR status needs

to be reviewed at regular intervals.

Audit is considered to be a useful tool to improve

clinical practice and The British Medical Association

(BMA) suggested that it should be used to monitor

the implementation of DNR policies. However,

there is very little published data in this area, for

which there may be a number of reasons. Firstly, an

effective audit needs to be carried out over a suffi-

cient period of time and studies are as yet incom-

plete. People may not consider DNR an area for

audit either because they mistakenly do not see it as

important or because it is in fact very difficult to

audit an ethical decision, as compared to a distinct

endpoint such as post operative death.

Discussion

There has been considerable interest in the lay press

over recent years about withholding treatment

(including CPR) and the medical profession can

probably expect an increasingly questioning

approach from patients in the future. The Govern-

ment has certainly signalled its intention to encour-

age this approach with the recent publication of its

Green Paper and the support which this gives to the

Law Commissions proposals to cover the use of

Living Wills.

In the light of all this, it is somewhat surprising that

there has not been much recent work published

which has looked at the practice of DNR decision

making. When the UK Health Service Commissioner

criticized the medical profession in 1991 for not

having uniform policies and procedures in relation to

resuscitation, the profession's response was to pro-

duce appropriate guidelines. The BMA guidelines

acknowledged that the way to develop practice could

well be through the use of audit. However, most of

the work that has been published looking at this area

actually preceded the publication of the guidelines.

The areas of deficiency in practice which have been

highlighted in the various surveys are very similar to

those about which the Health Service Commissioner

had expressed concern. It is possible that local audits

are taking place throughout the country developing

practice in line with the guidelines, although our

everyday clinical experience tells us that this is

probably not happening very much. Doyal and

Wilsher, two prominent ethicists, promised to audit

the implementation of DNR policies based on their

guidelines at a local teaching hospital. As far as we

are aware this work has not yet been published.

Why might it be that audit of DNR decision

making is not taking place to the extent that it was

anticipated? This could be related to a loss of

enthusiasm with the audit making principle as a

whole. As more clinicians have attempted to parti-

cipate in audit over the past few years, perhaps it

could be that they have found it more difficult to

carry out even relatively simple local audits than

was originally thought. The theory of completing

the audit loop and subsequently altering clinical

decision making sounds straightforward but is actu-

ally difficult in practice. Many of us have tried to

do this but seem to be unable to get past the initial

step of surveying current practice. The most suc-

cessful audits appear to be those conducted on a

national or regional level. The placing of a DNR

order is a very complex decision to make and

therefore may be daunting to audit. At local level

clinicians may be able to audit relatively uncompli-

cated interventions such as thrombolysis time.

However, it may appear to be a more difficult task

to audit a decision which has clinical, ethical and

practical aspects and involves the views of not only

doctors but also patients, their relatives and other



healthcare staff. In our work, we found that collea-

gues were much more reluctant to expose their

decision making about ethical issues to scrutiny

than they might have been to their management of

asthma or myocardial infarction.

At present it seems that audit is certainly the best

way forward for the UK to develop practice in this

area. Experience from the United States shows us

that legislation is not particularly effective and sim-

ply leads to rigid adherence to the `letter of the law'

rather than its underlying principles. If audit is to be

successful in DNR decision making then perhaps it

needs to be co-ordinated on a national or regional

level.

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The role of audit in making do not resuscitate decisions

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