Background For a significant number of patients suffering out-of-hospital cardiac arrest (OHCA) cardiopulmonary resuscitation (CPR) is likely to be futile and attempting it may be the wrong thing to do. Anticipatory care plans with do-not-attempt cardiopulmonary resuscitation (DNACPR) instructions exist to prevent this. Anecdotally we felt that many patients present to our Emergency Department (ED) with ongoing resuscitation which was not in their best interests. The aim of this study was to establish the proportion of patients arriving in our ED with ongoing CPR who had low, intermediate or high risk of futility.
Methods The survival outcome and past medical history of patients with OHCA brought into the ED of the Royal Infirmary of Edinburgh in 2015 were extracted from hospital records. Indicators of general deteriorating health and clinical indicators of underlying life limiting conditions were used to populate the Supportive and Palliative Care Tool (SPICT). The SPICT score was used as a measure of likely CPR futility. A SPICT score of 0–2 meant low risk of futility, 3–4 intermediate risk and >5 a high risk.
Results Of the 283 cases, 202 (71.4%) had a low risk of CPR futility; 46 (16.3%) an intermediate risk; and 35 (12.4%) were considered to be at high risk of CPR futility. In all low, intermediate and high risk categories, the commonest outcome was to be pronounced dead in A and E (55.4%, 73.9% and 71.4% respectively). For the low risk of futility group, a significant proportion (27.7%) survived to hospital discharge, whereas patients in the intermediate and high risk groups rarely survived with only 2.17% and 2.86% respectively discharged from hospital. Of the low, intermediate and high risk patients, 11.4%, 91.3% and 100% respectively had one or more significant underlying comorbidities.
Conclusions Our results suggest that community DNACPR implementation in Edinburgh is suboptimal, with many patients resuscitated and transported to the ED with ongoing resuscitation despite a high likelihood of futility. It is unclear what is required to improve this situation. Possible avenues for improvement may be more anticipatory care planning in the community, better recording of the outcomes of key conversations with patients and carers, or more consistent implementation of these plans by Ambulance Service responders. We plan further work to establish how this system can be changed to serve patients and their families better.
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