Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

• Published in: BMJ open 2018-10, Vol.8 (10), p.e024264-e024264
• Main Authors: Lightbody, Calvin J, Campbell, Jonathan N, Herbison, G Peter, Osborne, Heather K, Radley, Alice, Taylor, D Robin
• Format: Article
• Language: English
• Subjects: Advance directives; Clinical decision making; Decision making; Emergency medical care; Hospitals; Illnesses; Intervention; Mortality; Palliative care; Patient safety; Patient-Centred Medicine; Physicians; Systematic review
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2018-024264

ObjectivesTo assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.DesignA retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as ‘expected’ or ‘unexpected’ using the Gold Standard Framework Prognostic Indicator Guidance.SettingMedical, surgical and intensive care units of a district general hospital.OutcomesThe primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical ‘problems’ identified using the Structured Judgement Review Method.Results289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were ‘expected’. Among patients with ‘expected’ deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p