Advertisement

The Impact of Rapid Response Systems on Not-For-Resuscitation (NFR) Orders

  • Arthas FlabourisEmail author
  • Jack Chen
Chapter

Abstract

Rapid response teams (RRT) influence the issuing of NFR orders, with up to 24% of RRT calls involve documentation of NFR orders. This is to be expected as certain conditions demonstrate physiological disturbances as death approaches or such circumstances are precipitated by acute deterioration following an acute, unrelated illness. Furthermore, up to 35% of RRT calls are for patients with preexisting NFR orders, often within 24 h of their time of death. Overtime, RRT activity has evolved to be associated with issuing of other, related orders (e.g., not for RRT, modified RRT). The role of the RRT in end of life decisions and care will continue to evolve as RRT activity continues to increase and hospital wide strategies to better identify and manage patients at their end of life also evolve. There is potential for patient benefit of a closer association between critical care based RRT and palliative care services.

Keywords

Rapid response teams Not for resuscitation Palliative care 

References

  1. 1.
    Schein RMH, Hazday N, Pena M, et al. Clinical antecedents to in hospital cardiopulmonary arrest. Chest. 1990;98:1388–92.CrossRefPubMedGoogle Scholar
  2. 2.
    Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analysing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22:246–7.Google Scholar
  3. 3.
    Smith A, Wood J. Can some in-hospital cardio-respiratory arrest be prevented? Resuscitation. 1998;37:133–7.CrossRefPubMedGoogle Scholar
  4. 4.
    McQuillan P, Pilkington S, Alan A, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ. 1998;316:1853–8.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Goldhill DR, White SA, Sumner A. Physiological values and procedures in the 24 h before ICU admission from the ward. Anaesthesia. 1999;54:529–34.CrossRefPubMedGoogle Scholar
  6. 6.
    McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care units of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond. 1999;33:255–9.PubMedGoogle Scholar
  7. 7.
    Hillman KM, Bristow PJ, Chey T, et al. Antecedents to hospital deaths. Intern Med J. 2001;31:343–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Hillman KM, Bristow PJ, Chey T, et al. Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Med. 2002;28:1629–34.CrossRefPubMedGoogle Scholar
  9. 9.
    Hodgetts TJ, Kenward G, Vlackonikolis I, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation. 2002;54:115–23.CrossRefPubMedGoogle Scholar
  10. 10.
    Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K, and for the Intensive Care Society (UK) & Australian and New Zealand Intensive Care Society Clinical Trials Group ACADEMIA Study investigators. A comparison of Antecedents to Cardiac Arrests, Deaths and EMergency Intensive care Admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation. 2004;62:275–82Google Scholar
  11. 11.
    Rivers E, Nguyen B, Havstad S, et al for the Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy. N Engl J Med. 2001;345(19):1368–77Google Scholar
  12. 12.
    Clinical Care Committee of the Massachusetts General Hospital. Optimum care for hopelessly ill patients: A report of the Clinical Care Committee of the Massachusetts General Hospital. N Engl J Med. 1976;295:362–4.CrossRefGoogle Scholar
  13. 13.
    Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl J Med. 1976;295:364–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Burns JP, Edwards J, Johnson J, Cassem NH. Do-not-resuscitate order after 25 years. Crit Care Med. 2003;31:1543–50.CrossRefPubMedGoogle Scholar
  15. 15.
    Fukaura A, Tazawa H, Nakajima H, et al. Do not resuscitate orders at a teaching hospital in Japan. N Engl J Med. 1995;333:805–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Stern SG, Orlowski JP. DNR or CPR—the choice is ours. Crit Care Med. 1992;20:1263–72.CrossRefPubMedGoogle Scholar
  17. 17.
    Wright AA, Baohui Z, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665–73.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Decisions relating to cardiopulmonary resuscitation. A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing 2007.Google Scholar
  19. 19.
    Uhlmann RF, Cassel CK, McDonald WJ. Some treatment withholding implications of no code orders in an academic hospital. Crit Care Med. 1984;12:879–81.CrossRefPubMedGoogle Scholar
  20. 20.
    LaPuma J, Silverstein MD, Stocking CB, Roland D, Siegler M. Life sustaining treatment. A prospective study of patients with DNR orders in a teaching hospital. Arch Intern Med. 1988;148:2193–8.CrossRefGoogle Scholar
  21. 21.
    Sundararajan K, Flabouris A, Keeshan A, Cramey T. Documentation of limitation of medical therapy at the time of a Rapid Response Team call. Aust Health Rev. 2014;38:218–22.PubMedGoogle Scholar
  22. 22.
    Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ. 2005;330:1007–11.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    The MERIT Study Investigators. Introduction of medical emergency team (MET) system—a cluster-randomised controlled trial. Lancet. 2005;365:2091–7.CrossRefGoogle Scholar
  24. 24.
    Jones DA, McIntyre T, Baldwin I, Mercer I, Kattula A, Bellomo R. The medical emergency team and end-of-life care: a pilot study. Crit Care Resusc. 2007;9:151–6.PubMedGoogle Scholar
  25. 25.
    The Support Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;274:1591–8.CrossRefGoogle Scholar
  26. 26.
    van Delden JJ, Lofmark R, Deliens L, et al. Do-not-resuscitate decisions in six European countries. Crit Care Med. 2006;34:1686–90.CrossRefPubMedGoogle Scholar
  27. 27.
    Bedell SE, Pelle D, Maher PL, et al. Do-not-resuscitate orders for critically ill patients in the hospital. How are they used and what is their impact? JAMA. 1986;256:233–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Youngner SJ, Lewandowski W, McClish DK, et al. ‘Do not resuscitate’ orders: incidence and implications in a medical-intensive care unit. JAMA. 1985;253:54–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Stolman CJ, Gregory JJ, Dunn D, et al. Evaluation of the do not resuscitate orders at a community hospital. Arch Intern Med. 1989;149:1851–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Schwartz DA, Reilly P. The choice not to be resuscitated. J Am Geriatr Soc. 1986;34:807–11.CrossRefPubMedGoogle Scholar
  31. 31.
    Wachter RM, Luce JM, Hearst N, et al. Decisions about resuscitation: inequities among patients with different diseases but similar prognoses. Ann Intern Med. 1989;111:525–32.CrossRefPubMedGoogle Scholar
  32. 32.
    Hofmann JC, Wenger NS, Davis RB, et al. Patient preferences for communication with physicians about end-of-life decisions. SUPPORT investigators. Study to understand prognoses and preference for outcomes and risks of treatment. Ann Intern Med. 1997;127:1–12.CrossRefPubMedGoogle Scholar
  33. 33.
    Murphy BF. What has happened to clinical leadership in futile care discussions? Med J Aust. 2008;188:418–9.PubMedGoogle Scholar
  34. 34.
    Kuiper MA. Dying: domain of critical care medicine? Crit Care Med. 2012;40:316–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Bouley G. The rapid response team nurse’s role in end of life discussions during critical situations. Dimens Crit Care Nurs. 2011;30:321–5.CrossRefPubMedGoogle Scholar
  36. 36.
    Sulmasy DP, Sood JR, Ury WA. Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. J Med Ethics. 2008;34:96–101.CrossRefPubMedGoogle Scholar
  37. 37.
    Lynn J, Teno JM, Phillips RS, et al. Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med. 1997;126:97–106.CrossRefPubMedGoogle Scholar
  38. 38.
    Sidhu NS, Dunkley ME, Egan MJ. “Not-for-resuscitation” orders in Australian public hospitals: policies, standardised order forms and patient information leaflets. Med J Aust. 2007;186:72–5.PubMedGoogle Scholar
  39. 39.
    Morrell ED, Brown BP, Qi R, Drabiak K, Helft PR. The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after Patient Self-Determination Act. J Med Ethics. 2008;34:642–7.Google Scholar
  40. 40.
    Tulsky JA, Chesney MA, Lo B. See one, do one, teach one? House staff experience discussing do-not-resuscitate orders. Arch Intern Med. 1996;156:1285–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Micallef S, Skrifvars MB, Parr MJ. Level of agreement on resuscitation decisions among hospital specialists and barriers to documenting do not attempt resuscitation (DNAR) orders in ward patients. Resuscitation. 2011;82:815–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Prendergast TJ, Luce JM. Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med. 1997;155:15–20.CrossRefPubMedGoogle Scholar
  43. 43.
    Kollef MH, Ward S. The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit. Crit Care Med. 1999;27:2125–32.CrossRefPubMedGoogle Scholar
  44. 44.
    Hillman K, Flabouris A, Parr M. A hospital-wide system for managing the seriously ill: a model of applied health systems research. In: Sibbald WJ, Bion JF, editors. Update in intensive care and emergency medicine, Vol 35-Evaluating critical care, using health services research to improve outcome. Berlin: Springer; 2000.Google Scholar
  45. 45.
    Lam S, Flabouris A. Medical trainees and public safety. In: DeVita MA, Hillman K, Bellomo R, editors. Medical emergency teams, implementation and outcome measurement. 2006, ISBN: 0-387-27920-2Google Scholar
  46. 46.
    Austin Health, Respecting Patient Choices. http://www.respectingpatientchoices.org.au/. Accessed Dec 2008.
  47. 47.
    Parr MJ, Hadfield JH, Flabouris A, Bishop G, Hillman K. The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders. Resuscitation. 2001;50(1):39–44.CrossRefPubMedGoogle Scholar
  48. 48.
    Kenward G, Castle N, Hodgetts T, et al. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004;61(3):257–63.CrossRefPubMedGoogle Scholar
  49. 49.
    Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324:387–90.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Tan LH, Delaney A. Medical emergency teams and end-of-life care: a systematic review. Crit Care Resusc. 2014;16:62–8.PubMedGoogle Scholar
  51. 51.
    Cretikos MA, Chen J, Hillman KM, Bellomo R, Finfer SR, Flabouris A. The effectiveness of implementation of the medical emergency team (MET) system and factors associated with use during the MERIT study. Crit Care Resusc. 2007;9(2):206–12.Google Scholar
  52. 52.
    Buist M, Bellomo R. The medical emergency team or the medical education team. Crit Care Resusc. 2004;6:88–91.PubMedGoogle Scholar
  53. 53.
    Jaderling G, Calzavacca P, Bell M, et al. The deteriorating ward patient: a Swedish—Australian comparison. Intensive Care Med. 2011;37:1000–5.CrossRefPubMedGoogle Scholar
  54. 54.
    Calzavacca P, Licari E, Tee A, et al. Features and outcome of patients receiving multiple medical emergency team reviews. Resuscitation. 2010;81:1509–15.CrossRefPubMedGoogle Scholar
  55. 55.
    Casamento AJ, Dunlop C, Jones DA, Duke G. Improving the documentation of medical emergency team reviews. Crit Care Resusc. 2008;10:24–9.Google Scholar
  56. 56.
    Jones DA, Bagshaw SM, Barrett J, et al. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Crit Care Med. 2012;40:98–103.CrossRefPubMedGoogle Scholar
  57. 57.
    Coventry C, Flabouris A, Sundararajan K, Cramey T. Rapid response team calls to patients with a pre-existing not for resuscitation order. Resuscitation. 2013;84:1035–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Downar J, Rodin D, Barua R, Lejnieks B, Gudimella R, McCredie V, Hayes C, Steel A. Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: a multicentre retrospective study. J Crit Care. 2013;28:498–503.CrossRefPubMedGoogle Scholar
  59. 59.
    Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S, The MERIT Study Investigators. The medical emergency team system and not-for-resuscitation orders: results from the MERIT Study. Resuscitation. 2008;79:391–7.CrossRefPubMedGoogle Scholar
  60. 60.
    Fritza Z, Fulda J, Haydocka S, Palmer C. Interpretation and intent: a study of the (mis)understanding of DNAR orders in a teaching hospital. Resuscitation. 2010;81:1138–41.CrossRefGoogle Scholar
  61. 61.
    Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–42.CrossRefPubMedGoogle Scholar
  62. 62.
    Chen J, Ou L, Hillman KM, Flabouris A, Bellomo R, Hollis SJ, Assareh H. Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion. Med J Aust. 2014;201:167–70.CrossRefPubMedGoogle Scholar
  63. 63.
    Kansal A, Havill K. The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients. Crit Care Resusc. 2012;14:38–43.PubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Intensive Care Unit, Royal Adelaide Hospital and Faculty of Health Sciences, School of MedicineUniversity of AdelaideAdelaideAustralia
  2. 2.Simpson Centre for Health Services ResearchSouth Western Sydney Clinical School, University of New South WalesSydneyAustralia

Personalised recommendations