Pilot assessment of the utility and acceptability of a new ‘goals of care and not for cardiopulmonary resuscitation’ documentation tool/form

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Health care delivered at the end of life should aim to deliver the outcomes desirable to the patient and family. Understanding the priorities for the outcome of care requires open and honest communication about health care options, prognosis, likelihood of survival and risks for cognitive impairment or functional decline. As prediction of death in any one admission is difficult, conversation about goals of care and undesirable outcomes should occur for those patients who are at risk of dying in the next 12 months (Gibbins, McCoubrie, Alexander, Kinzel, & Forbes, 2009). Completion of an NFR form is often the result of the conversation regarding outcomes acceptable to the patient or which may have a reasonable chance of success. The survival to discharge outcomes for CPR in those aged 80 years and over is poor and there is significant morbidity especially in impaired cognitive function. However, the completion rate of NFR in the first 24 hours for those patients aged 80 years and over admitted acutely unwell to public or private hospitals is less than 20%. (Levinson and Mills, 2016 (in press)). The rate is significantly lower in private compared to public hospitals. Hospitals and the Australasian College for Emergency Medicine policy around NFR documentation strongly encourages discussion of resuscitation status with the patient. While NFR completion does not confirm that discussion of goals of care has occurred, absence of NFR in those who have a poor outcome from CPR (hospital inpatients aged 80+ years) is highly suggestive of an absence of goals of care discussion at least as it relates to acute deterioration and resuscitation. There are many published barriers to end of life conversations. These include time, knowledge of the law, expertise and a desire not to rob the patient of hope. At Cabrini there are no decision-making tools to assist with the issues to be addressed at end of life. There is a perceived need for a goals of care discussion to be documented in the patient file (personal communication senior nursing staff 4S, 3C and MET registrars) associated with the completion of NFR if appropriate to improve patient centred care and reduce futile cardiopulmonary resuscitation. The aim of this study is to evaluate the utility and relevance of a document to assist with the conversation about goals of care at the end of life, and to facilitate the completion of Not For Resusitation forms where appropriate in the Emergency Department at Cabrini Malvern. The forms will be trialed over a 12 week period. At the end of this time, the forms will be evaluated for: Adequacy and completeness of the documentation the utility and acceptability of the GCR forms in guiding and promoting discussion Evaluate the interviews for themes relating to use of the forms. Evaluation of patient outcomes (length of stay; discharge or death) and evidence of discussion documentation

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