Think DNAR: a QIP
Introduction: Advanced care planning (ACP) is the process of making decisions about future care.1,2 It is essential to ensuring patients’ wishes are followed and that the last period of their life is guided by them. One of the six ACP principles stated by NHS England is the need for ACP decisions to...
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Elsevier
2025-06-01
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| Series: | Future Healthcare Journal |
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| description | Introduction: Advanced care planning (ACP) is the process of making decisions about future care.1,2 It is essential to ensuring patients’ wishes are followed and that the last period of their life is guided by them. One of the six ACP principles stated by NHS England is the need for ACP decisions to be shareable.1 While it is important to regularly revisit ACP decisions, preventing restarting what can be upsetting conversations through good documentation is both more efficient and kinder.3 In Wales, there are no consistently used ACP documents. The significance of this is that patients with no documented ACP are at increased risk of unwanted investigations and unnecessary hospital admissions.2,4 81% of people aged 75 years and older had at least one hospital admission in their last year of life; thus, establishing and following their wishes should be our priority.5 Aims, materials and methods: The project aims were to improve the communication of do not attempt resuscitation (DNAR) discussions had in hospital to GPs. Stakeholder engagement with GPs, consultants and resident doctors raised issues such as a lack of consistency in achieving patients’ wishes and duplication in work due to no formal documentation. These data were modelled using a fishbone diagram (Fig 1) to give better insight into contributing factors.My baseline measurements were gathered by using the medical notes and the nursing notes via Clinical Workstation to attain the resuscitation status of patients. On discharge, mentions of resuscitation status were then identified in the Discharge Advice Letters (DALs) and recorded. Following a plan–do–study–act (PDSA) cycle, posters were then implemented encouraging resident doctors to communicate DNAR decisions via DALs. 16 doctors (FY2s and GPST1s) were involved. 61 patients’ notes were initially looked at in phase one and 51 in phase 2. All patients from the wards were included to avoid age-related bias that is associated with ACP planning. Patients who were present for both cycles were only include in phase 2 and patients who died were excluded. Results and discussion: The data showed that, while a similar number of people had DNARs (45% compared with a previous 44%), more patients had these decisions communicated in their DALs (40% compared with 26% previously).The strengths of the project were that the posters have remained up to promote sustained communication of resuscitation status. Using a PDSA design has been ideally suited allowing for dynamic changes responding to the unique pressures of the system and stakeholder feedback.6 A rise in the number of DALs stating resus status supports its success.However, the limitations were that posters are only prompts, whereas contextual understanding, such as education, promotes increased adoption of interventions. An educational session on the importance of inclusion ACP in DALs is planned to further address this.6,7 This is supported by anecdotal feedback from the first PDSA cycle that ACP is not considered in most DALs. Conclusion: The addition of posters helped to improve the number of DALs that included ACP; however, further optimisation through interventions such as education, with higher levels of effectiveness, is required. |
| format | Article |
| id | doaj-art-aa91e9ff1c1b4bbaae93bd05726e2505 |
| institution | DOAJ |
| issn | 2514-6645 |
| language | English |
| publishDate | 2025-06-01 |
| publisher | Elsevier |
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| spelling | doaj-art-aa91e9ff1c1b4bbaae93bd05726e25052025-08-20T03:13:57ZengElsevierFuture Healthcare Journal2514-66452025-06-0112210044110.1016/j.fhj.2025.100441Think DNAR: a QIPImogen Potter0University Hospital of WalesIntroduction: Advanced care planning (ACP) is the process of making decisions about future care.1,2 It is essential to ensuring patients’ wishes are followed and that the last period of their life is guided by them. One of the six ACP principles stated by NHS England is the need for ACP decisions to be shareable.1 While it is important to regularly revisit ACP decisions, preventing restarting what can be upsetting conversations through good documentation is both more efficient and kinder.3 In Wales, there are no consistently used ACP documents. The significance of this is that patients with no documented ACP are at increased risk of unwanted investigations and unnecessary hospital admissions.2,4 81% of people aged 75 years and older had at least one hospital admission in their last year of life; thus, establishing and following their wishes should be our priority.5 Aims, materials and methods: The project aims were to improve the communication of do not attempt resuscitation (DNAR) discussions had in hospital to GPs. Stakeholder engagement with GPs, consultants and resident doctors raised issues such as a lack of consistency in achieving patients’ wishes and duplication in work due to no formal documentation. These data were modelled using a fishbone diagram (Fig 1) to give better insight into contributing factors.My baseline measurements were gathered by using the medical notes and the nursing notes via Clinical Workstation to attain the resuscitation status of patients. On discharge, mentions of resuscitation status were then identified in the Discharge Advice Letters (DALs) and recorded. Following a plan–do–study–act (PDSA) cycle, posters were then implemented encouraging resident doctors to communicate DNAR decisions via DALs. 16 doctors (FY2s and GPST1s) were involved. 61 patients’ notes were initially looked at in phase one and 51 in phase 2. All patients from the wards were included to avoid age-related bias that is associated with ACP planning. Patients who were present for both cycles were only include in phase 2 and patients who died were excluded. Results and discussion: The data showed that, while a similar number of people had DNARs (45% compared with a previous 44%), more patients had these decisions communicated in their DALs (40% compared with 26% previously).The strengths of the project were that the posters have remained up to promote sustained communication of resuscitation status. Using a PDSA design has been ideally suited allowing for dynamic changes responding to the unique pressures of the system and stakeholder feedback.6 A rise in the number of DALs stating resus status supports its success.However, the limitations were that posters are only prompts, whereas contextual understanding, such as education, promotes increased adoption of interventions. An educational session on the importance of inclusion ACP in DALs is planned to further address this.6,7 This is supported by anecdotal feedback from the first PDSA cycle that ACP is not considered in most DALs. Conclusion: The addition of posters helped to improve the number of DALs that included ACP; however, further optimisation through interventions such as education, with higher levels of effectiveness, is required.http://www.sciencedirect.com/science/article/pii/S2514664525002206 |
| spellingShingle | Imogen Potter Think DNAR: a QIP Future Healthcare Journal |
| title | Think DNAR: a QIP |
| title_full | Think DNAR: a QIP |
| title_fullStr | Think DNAR: a QIP |
| title_full_unstemmed | Think DNAR: a QIP |
| title_short | Think DNAR: a QIP |
| title_sort | think dnar a qip |
| url | http://www.sciencedirect.com/science/article/pii/S2514664525002206 |
| work_keys_str_mv | AT imogenpotter thinkdnaraqip |