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 AustraliaRavi RUBERU Geriatric Registrar, Royal Adelaide HospitalCampbell THOMPSON Professor of General Medicine, University of Adelaide

Harm, Health and ResponsibilityAABHL 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 residenceTotal Home Residential

Aged Care Facility – low

Residential Aged Care Facility – high

Unknown

Total 99 78 4 16 1

With documentation

34

20 Males14 Females

22 1 11 -

No current documentation but previous

2 (both female)

1 - 1 -

Findings3 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