Academic journal article Australian Health Review

Documentation of Limitation of Medical Therapy at the Time of a Rapid Response Team Call

Academic journal article Australian Health Review

Documentation of Limitation of Medical Therapy at the Time of a Rapid Response Team Call

Article excerpt

Not-for-resuscitation (NFR) orders are not infrequent.1-3 Hospi- tal policies in relation to NFR orders were first published in 1976.4,5 Since then there has been much discussion and contro- versy associated with NFR orders.6-8 The controversies have primarily revolved around the fact that there have been incon- sistencies and inadequacies in the documentation of such orders and as to whether clinician bias, compared with patient factors, was driving the process.9-11

The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)12 did not show an improvement in the rapport between the patient and clinician, even though it considerably increased the documentation of existing limitations in medical therapy (LMT) orders. Further- more, despite the development of academic palliative care pro- grams, documentation of do not resuscitate (DNR) orders remained unsatisfactory, even in the group of patients who were expected to die.13

There are several reasons why documentation of LMT orders is inadequate and ineffectual. The most important rate-limiting step in the documentation process is a transparent discussion between the physician and the patient about the patient's prog- nosis and management. The barriers to commence these discus- sions,14 as alluded to in previous studies, include: physicians' distress and anxiety in dealing with end-of-life discussions; the apprehension of harming the relationship with their patients; challenging, demanding family members; and the time-consum- ing nature of difficult family meetings and the emotional drain associated with such meetings. Sometimes patients are not even offered the opportunity to discuss these issues.15

There are also issues surrounding how LMT orders are documented. Documentation can be misconstrued and so fail to redirect changes in end-of-life care.15 Similarly, even when discussions about end-of-life and decisions on LMT were un- dertaken by senior medical clinicians, the actual documentation has been left to the junior medical staff.16

It has been well established that rapid response teams (RRT) have an important role in the issuing of NFR orders.6-9 RRT were introduced to respond promptly to acutely unwell patients so as to reduce serious adverse events, such as unanticipated intensive care unit (ICU) admissions, cardiac arrests and deaths.17 RRT are typically staffed by members with advanced life support skills, based within a critical care area and equipped to deliver advanced resuscitation and critical care skills.18 Not surprisingly, many of these calls occur afterhours.19

The Medical Early Response Intervention and Therapy (MERIT)study,20acluster randomised control studyofa Medical Emergency Team (MET) versus conventional cardiac arrest teams, demonstrated that more NFR orders were issued at the time of a MET call than at calls associated with a conventional cardiac arrest team.20 RRT document an NFR order in up to 5% of RRT calls.6 This is not that surprising considering that RRT attend up to 30% of dying patients.21,22 MET were also more likely to attend patients with a prior NFR order than conventional cardiac arrest teams6 and potentially improve the delivery of end- of-life care to dying patients.23,24

Little is known about the timing and circumstances surround- ing the issuingofan LMT orderduringan RRTcall. Thisis crucial because these orders are being made by doctors who may be encountering the patient for the first time, during an acute event and at a time when the patient may not be competent to participate in such decisions.

Aims and objectives

The objectives of the present study were to describe the circum- stances surrounding the issuing and documentation of LMT orders at the time of an RRT call, and to compare these with similarly documented orders that were not associated with an RRT call.


Ethics approval

This study was approved by the Royal Adelaide Hospital Human Research Ethics Committee (approval no. …

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