In Australia, when an inpatient suffers a cardio-pulmonary arrest, resuscitation has become the default response, unless there is clear documentation in the clinical chart that the patient is not to be resuscitated.1 There is no national standardised approach or protocol for communicating and documenting clinical resuscitation orders,2 though there is evidence that using a standardised resuscitation order form facilitates better end-of-life decision-making.3
Historically in Queensland there has been wide variation in the content of hospital not-for-resuscitation (NFR) policies and NFR order forms providing potential for poor patient outcomes and medico-legal risks. Following a number of coronial inquests,4,5,6,7 it was recommended that Queensland Health (QH) review its practice and documentation of NFR orders. In response to this, the Acute Resuscitation Plan (ARP) document (Appendix 1) was developed as a standardised medical order form. As of April 2010, it became a procedure in QH to document clinical recommendations and discussions regarding resuscitation on the ARP.8
The ARP is an important adjunct to Advance Care Planning (ACP) documents. Unlike an advance care plan, which is completed by a patient or a substitute decision maker, the ARP is completed by a medical officer after considering the patients’ clinical status and their choices for end-of-life care. It focuses primarily on resuscitation planning, an important step to allow realisation of a patient’s advance care plan8. Rather than just documenting the treatments that will not be provided, as in previous NFR orders, the ARP requires the medical officer to document treatments and cares that will be provided, thus offering a comprehensive approach to resuscitation planning.
Clinically an ARP should be completed where it is expected that an adult patient may suffer an acute deterioration or cardio-pulmonary arrest in the foreseeable future. Hence it can be used to guide timely discussion with the patient and/or their substitute decision-maker(s) about the patient’s prognosis and realistic outcomes of an attempted resuscitation.8
The ARP also records details about a patient’s capacity to make health care decisions at the time of its completion and indicates whether the patient has an Advance Health Directive and/or substitute decision maker(s). An ARP is only a medical order and does not in itself give consent to initiate, withhold or withdraw life-sustaining measures. Except in emergency situations, if the patient lacks capacity consent is always required by law to act on the ‘Resuscitation Management Plan’ documented in the ARP.
In Queensland, consent should be obtained using the following hierarchy, in order:9
1. The patient’s Advance Health Directive (AHD).
2. Guardian(s) appointed by the QCAT (Queensland Civil and Administrative Tribunal).
3. Health attorney(s) appointed under the most recent enduring document.
4. The patient’s statutory health attorney(s).
5. The Public Guardian.
Unlike previous NFR orders, the ARP document follows a consistent decision-making pathway complying with Queensland’s Guardianship and Administration Act (2000) and Powers of Attorney Act (1998) 10 thereby addressing the complex legal and ethical framework that surrounds end-of-life care, particularly in patients who lack capacity to make health care decisions.
Queensland Health Patient Safety Unit has developed resources and tools to help hospitals meet the National Safety and Quality Health Service (NSQHS) standards.11 The ARP document addresses elements of the NSQHS – Standard 9 which is ‘Recognising and Responding to Clinical Deterioration in Acute Health care’. 12 In addition to the NSQHS requirements, Queensland legislation mandates clear documentation of all decisions that are made regarding withholding and withdrawing of life-sustaining measures.13 To meet this requirement, an ARP document should have all domains duly completed prior to being placed preferentially at the front of the clinical chart to allow easy access in an emergency. The medical officer attending a patient’s medical emergency team (MET) call, especially after hours, may not be the primary treating doctor and a completed ARP provides the attending doctor with the agreed resuscitation management plan for that patient. Information about a patient’s advance care plan, clinical treatment plan and goals of care should be readily available to all clinicians involved in the patient’s care.14,15
In the Brisbane hospital where this audit was conducted, it is policy that ARPs along with substitute decision-maker supporting documents should be placed in front of the patient clinical chart for easy accessibility. Lack of clarity in ARP documentation or the inability to locate the ARP during a medical emergency may result in inappropriate cardio-pulmonary resuscitation (CPR) or other interventions being administered.16
Compared to other treatment measures, decisions concerning resuscitation planning are often inadequately discussed and documented.17,18,19 Inadequate medical documentation is often cited as a correctable weakness that exposes doctors to complaints and litigations.20 A well structured documentation of the end-of-life discussions and resuscitation planning is the safest and the easiest way of informing medical officers, nursing and allied health staff about resuscitation decisions thus increasing the likelihood of patient-centered quality end-of-life care.21
Despite the importance of correctly completing ARPs, the hospital where this study was carried out does not conduct regular formal education sessions for medical officers on how to complete ARPs. Anecdotally, inconsistencies and inaccuracies in ARP documentation and difficulties in accessing supporting documentation had been identified in daily practice at this hospital. As a part of the hospital’s quality improvement process, it was decided to undertake an audit to explore the accuracy and completion of ARPs, visibility of the ARP in the clinical chart and availability of any supporting documents mentioned in the ARP
DISCUSSION
This audit revealed several areas of incomplete documentation within ARPs, importantly in the domains of patient capacity assessment, consenting details and clinical authorisation. In addition, there were few supporting ACP documents filed within the medical charts. These findings have potential implications for the delivery of appropriate care to patients when an expected deterioration occurs, especially at end-of-life.
Previous studies examining the quality of documentation for resuscitation planning have reported variation in the consistency and the accuracy of documentation,16,22,23 though Butler et al3 showed that the use of a standardised NFR order improves the resuscitation planning documentation process. This audit demonstrates that even with the use of a standardised resuscitation order form there can be variability in the accuracy of documentation.
CLINICAL ASSESSMENT OF THE PATIENT
This domain forms an important part of the ARP. When appropriately completed it should list the relevant medical conditions relating to the patient’s physical and/or mental health as these usually contribute to the clinical triggers that prompt the medical team to initiate resuscitation planning. It may also include other clinical reasons as to why resuscitation planning is necessary.24 This audit revealed that there was a 12% mismatch between the diagnosis documented on the ARP and the actual diagnosis documented in the clinical chart. This degree of mismatch may represent a clinically significant medico-legal risk as appropriate resuscitation management depends on quality clinical assessment. A mitigating circumstance is that in those patients with a diagnosis mismatch, resuscitation planning might have taken place based on the correct diagnosis in the clinical chart. Since this audit is unable to verify that, this finding should be viewed as a quality improvement opportunity.
RESUSCITATION MANAGEMENT PLAN
This section should provide an unambiguous direction to clinicians attending a patient’s episode of clinical deterioration or cardiac arrest as to what is required, and in the best interest of, a particular patient. If the patient and health care team have made the decision that CPR is not to be provided, the ‘provide’ and ‘not provide’ sections are intended to indicate a level of appropriate intervention. This was the only domain of the ARP that was completed in 100% of cases. This raises the possibility that medical officers are using the ARP simply as NFR order. However unlike NFR orders, ARPs should not only be used to document resuscitation status but also to record patient’s wishes and views on other aspects of end-of-life care like pain management options, spiritual and cultural support. 24
PATIENT CAPACITY ASSESSMENT & SUBSTITUTE DECISION MAKER DETAILS
All adults are presumed to have capacity unless determined not to have capacity by clinical assessment.9 Decision-making capacity must be assessed for a specific decision and assumptions cannot be made based on the patients’ diagnosis.25 If there are any doubts or uncertainties about the patient’s capacity, the medical officer should undertake a capacity assessment and the form of assessment undertaken should be documented clearly on the ARP.9
In this audit, almost half of the patients were deemed to lack capacity to make health care decisions and more than half of their ARPs did not have any form of capacity assessment documented. This is an important issue as decision-making about withholding or withdrawing life sustaining measures in patients who lack capacity is more complex than in those patients with capacity. The laws that surround such decision-making differ across various states and territories in Australia.26 It is of utmost importance that medical officers involved in making such decisions be educated and be made aware of the current health law. In Queensland it is an offense for a clinician to carry out any health care, including initiation, withholding or withdrawing life sustaining treatments for a person with impaired capacity unless there is consent from a suitably approved substitute decision-maker, an advance health directive or a tribunal appointed guardian. Clinicians must obtain consent before withholding or withdrawing life sustaining measures, even if considered futile by the treating clinician.26 This can lead to the perception that there is tension between best medical practice and Queensland legislation. Given the uniqueness of Queensland law, clinicians would be well advised to carefully complete the capacity assessment domain of the ARP to provide medico-legal surety for all doctors who attend a clinically deteriorating patient.
Research has shown that among Australian doctors there are some significant knowledge gaps about the law on withdrawing and withholding life sustaining treatments from adults who lacks capacity.27 This lack of clarity about health law can put patients and doctors at significant risk. In patients who lack capacity, if life sustaining measures are withheld or withdrawn, without consent from an appropriate substitute decision maker, it can be seen as their lives being ended unlawfully. Conversely, life sustaining measures may be provided, despite refusal of those measures by an AHD or a substitute decision maker, thus infringing patients’ legal rights. 28 Criminal responsibilities could arise for murder or manslaughter in situations where life sustaining measures are withheld or withdrawn unlawfully29 and for assault where life sustaining measures are provided without appropriate consent. 30
As shown in the results, the ‘Consenting Details’ domain was poorly completed and documentary evidence of substitute decision makers in the patients’ clinical charts was scarce. Given the significance of this domain and the potential medical-legal risks that can arise from incomplete documentation, this must be seen as an important target for quality improvement in this hospital.
CLINICAL AUTHORISATION OF THE DOCUMENT
The documentation of the ARP should include the medical officer’s name, signature, date as well a document review time. It is a requirement by Queensland Health that the consultant/ senior medical officer or the registrar should complete and sign the ARP document.24 While junior medical officers are encouraged to participate in resuscitation planning, it is not recommended that they complete ARPs. In unavoidable circumstances (e.g. in remote hospitals) a junior medical officer may complete an ARP but it must be authorised by a senior medical officer within a reasonable timeframe. As indicated in the results, this important domain was poorly completed, suggesting a need for medical education in this area.
LOCATION OF ARPs IN THE CLINICAL CHART
Studies done previously have highlighted difficulties in locating the documentation of resuscitation planning in the clinical chart.31 In this audit, the ARPs for all live patients were located at the front of the clinical chart as mandated by hospital policy. In deceased patients however, the ARPs had been moved from the front to the ‘Correspondence section’ of the clinical chart, also as mandated by hospital policy. This policy is likely to place hospital at legal risk, because it cannot be known if, at the time of death, the ARP was in an easily accessible place to inform the appropriate resuscitation plan. To mitigate risk, a change in hospital policy and practice so that ARPs of deceased patients remain at the front of their clinical charts may be advantageous.
TIME BETWEEN ARP COMPLETION AND DEATH
Early identification of patients at risk of dying facilitates high quality end-of-life care by promoting proactive coordination and integration of care across all clinical teams and ensures more timely access to specialist palliative care services, if required.15 Diagnosing dying or identifying patients at risk of dying is an essential and the most fundamental step in providing safe and high quality end-of-life care.14,32 The time between ARP completion and subsequent death could provide an indirect measure that treating clinicians recognised that the patient was at risk of dying. As shown in the results, the average time between ARP completion and death in this audit is approximately 4 months indicating that for patients with a completed ARP, there was appropriate recognition of risk of death. The median time was 24 days which shows that end-of-life care discussions were held atleast 3 weeks prior to death in half of the deceased patient population.
COMPLIANCE WITH THE ARP ORDER AT THE TIME OF DEATH
In this study, MET were called in less than 1% of the patient population and CPR was not performed in any of them in alignment with ARP content. Though this represents a small number of patients it indicates that the ARP was followed at the end of life.