1. 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 Australia Ravi RUBERU Geriatric Registrar, Royal Adelaide Hospital Campbell THOMPSON Professor of General Medicine, University of Adelaide Harm, Health and Responsibility AABHL 2012

2. Aim To examine the nature and prevalence of resuscitation decisions documented in in-patient clinical notes. Pilot Study

3. Selection criteria 70 yrs + Within 48 hrs of admission General Medicine

4. 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.

5. Findings Resuscitation documentation in 34 of 99

6. Place of residence TotalHome Residential Aged Care Facility – low Residential Aged Care Facility – high Unknown Total 99784161 With documentation 34 20 Males 14 Females 22111- No current documentation but previous 2 (both female) 1-1-

7. Findings 3 full resuscitation 3 no resuscitation or emergency measure 28 of 34 were for MET calls

8. Documentation lacked consistency some were difficult to read and or interpret no consistent use of language or terms

9. 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

10. Advance care directives Advance care directives were mentioned in two case notes but neither were available to the medical staff

11. 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

12. 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

13. 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

14. 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 METS

15. Terms used (cont) 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 ward measure Full resus Agressive/invasive Rx Comfort care Comfort measures Conservative ward Rx Only for conservative ward Rx

16. 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)

17. Conclusion - Recommendations Clinical Guidelines Advance care planning Public debate

18. 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?”

19. “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