How might a ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decision affect other aspects of patient care? A vignette-based randomised study

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INTRODUCTION: Patients and clinicians often question whether a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision might affect the attention paid to other aspects of patient care, or their access to interventions unrelated to Cardiopulmonary Resuscitation (CPR). We set out to directly test this proposition using a clinical vignette. METHODS: We presented a clinical scenario of a deteriorating patient to 226 senior geriatricians and specialist trainees. Using a double-blind approach, different geriatricians received alternative versions of the scenario which differed only in whether a DNACPR decision was in place. RESULTS: In responding to a series of questions about escalation of care, the 110 respondents (48.7%) took a significantly different approach to two versions of the scenario. Non-invasive ventilation for type 2 respiratory failure was considered by only 67.3% of geriatricians if a DNACPR decision was in place, compared to 83.6% (P < .05) in its absence. The presence of a DNACPR decision led to less than half as many geriatricians responding that they would consider intensive care (10.9% vs. 25.5%; P < .05). CONCLUSIONS: All clinicians need to be aware that a patient's DNACPR status may lead to unconscious bias when other decisions are made, especially in busy acute settings. These findings should inform how we respond to case presentations and train resident doctors, highlighting the need for more sophisticated approaches to treatment escalation plans so these capture the nuances of discussion of patients' priorities rather than just document DNACPR status.

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