Do-Not-Attempt-Cardiopulmonary-Resuscitation decisions in the hospital setting

Background: A Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) order can be placed when CPR is not in accordance with the patient’s will, when CPR is considered not to benefit the patient, or when CPR is very unlikely to be successful because the patient is dying from an irreversible condition. The decision to withhold CPR involves assessment of the predictors for favourable outcome, in compound with the patient’s values and goals of care to make a decision that is of benefit to the patient. Throughout this process there are ethical directives and legislations to relate to. Previous studies have shown that it is difficult for medical personnel to accurately predict outcome after cardiac arrest, but there is no supportive prediction model established in clinical practice. There are indications of shortages in adherence to legislation regarding DNACPR orders in our setting, but clinical practice has not been evaluated on a larger scale. Further, there is scarce knowledge about the grounds for DNACPR decisions based on the clinical practice, about the use of DNACPR orders, and the characteristics of those receiving them. Aims: The overall aim of this thesis was to facilitate and investigate the decision process for DNACPR order placement in the hospital setting and fill knowledge gaps in the epidemiology of DNACPR orders. More specifically, the aim was external validation of the pre-arrest prediction model the Good Outcome Following Attempted Resuscitation (GOFAR) score (study I), model update of the GO-FAR score with development of a prediction model for the Swedish setting (study II), evaluation of adherence to the Swedish legislation regarding documentation of DNACPR order placement, exploration of the decision process in clinical practice (study III), and assessment of the use of DNACPR orders, characteristics and outcome for the patients (study IV). Methods: Study I and II included adult in-hospital cardiac arrests (IHCA) in the Swedish Registry for Cardiopulmonary Resuscitation (SRCR) from 2013 to 2104 in the Stockholm region. Outcome in study I was neurologically intact survival defined as Cerebral Performance Category score (CPC) 1 and in study II outcome was favourable neurological survival defined as CPC 1–2. Outcome and patient characteristics were retrieved from SRCR, predictor variables from manual review of electronic patient records and from the National patient registry (NPR). External validation of the GO-FAR score was based on assessmen