Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice

Background: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR. Methods: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019. Results: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001). Conclusion: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.