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A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation

      To the Editor
      Some patients wish to forgo cardiopulmonary resuscitation (CPR) should they have a cardiac arrest. Unfortunately, there have been instances of CPR being performed despite a documented decision of do-not-resuscitate (DNR),
      • Baxter L.
      • Hancox J.
      • King B.
      • Powell A.
      • Tolley T.
      STOP! patients receiving CPR despite valid DNACPR documentation.
      • Findlay G.P.
      • Shotton H.R.
      Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest.
      but few studies have discussed why this occurs.
      A retrospective chart review was completed on all adult patients who had a cardiac arrest with CPR done between January 2012 and December 2018 at the Minneapolis Veteran Affairs Health Care System. A total of 327 patients underwent CPR during that timeframe. Nine (2.8%) were identified as undesired administration of CPR (Table 1). Seven (78%) patients had return of spontaneous circulation (ROSC), but only 3 (43%) survived more than 24 h post resuscitation.
      Table 1Description of nine DNR patients who underwent CPR.
      Case NoAge (years)ROSC (achieved)Time survivedLocationReason for CPR
      Case 173YesSeveral hoursICUPhysician overrides code status
      Case 280Yes<1 hIR suitePhysician overrides code status
      Case 374No--
      Did not survive cardiac arrest.
      EDNot aware of POLST until later
      Case 467Yes<1 hFloorUnaware of DNR status
      Case 566No--
      Did not survive cardiac arrest.
      FloorUnaware of DNR status
      Case 663Yes11 monthsFloorUnaware of DNR status
      Case 781YesSeveral hoursFloorUnaware of DNR status
      Case 867Yes3 daysFloorUnaware of DNR status
      Case 966Yes4 monthsICUUnaware of DNR status
      ROSC = return of spontaneous circulation, ICU = intensive care unit, IR = interventional radiology, ED = emergency department.
      a Did not survive cardiac arrest.
      Case 1: Cardiac arrest occurred after tracheostomy dislodgement, CPR started despite treatment team’s awareness of DNR status.
      Case 2: Patient elected to remain DNR when discussed prior to procedure. Cardiac arrest occurred after moderate conscious sedation administered and CPR started.
      Case 3: Patient brought in by paramedics and cardiac arrest occurred. CPR started, but stopped after Physician’s Order for Life Sustaining Treatment (POLST) was found in the ambulance.
      Cases 4–9: The remaining cases of cardiac arrest occurred in the inpatient setting, with the responding provider unaware of the patient’s DNR status. Five of these cases had a documented DNR order in the chart, while in the remaining case it had not yet been ordered. In three of the cases, DNR status was discovered during course of CPR and compressions were terminated.
      In our study, factors that contributed to undesired CPR include: physicians overriding code status, failure to effectively disseminate and honor advanced directives, and unawareness of a patient’s code status. Cases 1 and 2 describe instances where physicians attempted resuscitation despite previously discussed DNR wishes. This may occur if physicians believe the arrest was due to physician error or procedural complication, and not all potential scenarios can be discussed. A survey found that 29% of physicians “certainly would” override a DNR order in the case of a complication leading to cardiac arrest and 69% would in the case of a physician error.
      • Casarett D.J.
      • Stocking C.B.
      • Siegler M.
      Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic?.
      Even if a resuscitation is thought likely to be successful, seeking to correct the error can lead to further interventions and harms without the ability of the patient to provide informed consent. Another reason patients receive undesired CPR is unawareness or feeling uncomfortable honoring life sustaining treatment decisions made through outpatient documents (advance directive or POLST). Moreover, POLST or advanced directives may not always accompany patients. Several of our cases illustrate examples of undesired CPR due to unawareness of patient’s DNR status. This mistake can occur given the multiple hand-offs each day between different teams of medical staff and often the resuscitation team is not familiar with the patient. Studies have found more than a 10 % discordance between an ordered code status and sign-out documentation and between patient reported and physician ordered resuscitation preference.
      • Young K.
      • Wordingham S.
      • Strand J.
      Discordance of patient-reported and clinician-ordered resuscitation status in patients hospitalized with acute decompensated heart failure.
      • Aylward M.J.
      • Rogers T.
      • Duane P.G.
      Inaccuracy in patient handoffs: discrepancies between resident-generated reports and the medical record.
      More studies are needed to devise better methods of communicating code status at the bedside in a discrete but quickly accessible manner.

      Source of funding

      None.

      Declaration of interests

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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        • Tolley T.
        STOP! patients receiving CPR despite valid DNACPR documentation.
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