What is actually written? Resuscitation documentation in clinical case notes: ethical, legal and...
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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
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Aim
To examine the nature and prevalence of resuscitation decisions documented in in-patient clinical notes.
Pilot Study
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Selection criteria
•70 yrs +
•Within 48 hrs of admission
•General Medicine
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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.
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Findings
Resuscitation documentation in 34 of 99
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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 -
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Findings3 full resuscitation
3 no resuscitation or emergency measure
28 of 34 were for MET calls
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Documentation
lacked consistency
some were difficult to read and or interpret
no consistent use of language or terms
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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
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Advance care directives
Advance care directives were mentioned in two case notes but neither were available to the medical staff
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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
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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
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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
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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
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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
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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)
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Conclusion - Recommendations
Clinical Guidelines
Advance care planning
Public debate
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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?”
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“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
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