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

Resuscitation. 2020 Oct;155:172-179. doi: 10.1016/j.resuscitation.2020.08.006. Epub 2020 Aug 20.


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.

Keywords: Advance directives; COVID-19; Electronic health records; Resuscitation orders.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • COVID-19
  • Cardiopulmonary Resuscitation / methods
  • Cardiopulmonary Resuscitation / statistics & numerical data*
  • Clinical Decision-Making / ethics*
  • Cohort Studies
  • Coronavirus Infections / epidemiology*
  • Coronavirus Infections / therapy*
  • Critical Illness / mortality
  • Databases, Factual
  • Delivery of Health Care / trends
  • Female
  • Hospital Mortality / trends
  • Hospitals, Teaching
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Pandemics / prevention & control
  • Pandemics / statistics & numerical data*
  • Pneumonia, Viral / epidemiology*
  • Pneumonia, Viral / therapy*
  • Resuscitation Orders / ethics*
  • Retrospective Studies
  • United Kingdom