Emergency medical service providers' experience with family presence during cardiopulmonary resuscitation

OBJECTIVE: To describe emergency medical service providers' experiences with family member presence during resuscitation, and to determine whether those experiences are similar within urban and suburban settings. METHODS: We conducted a personally distributed survey of a convenience sample of urban and suburban emergency medical service (EMS) providers presenting to two Midwestern Emergency Departments. Providers were questioned as to their experiences with resuscitating patients in the presence of family members. RESULTS: There were 128 respondents to the survey (59 urban and 69 suburban), of which 70.1% were EMT-Paramedics. No provider who was approached refused participation. Nearly all (122) had performed CPR in the presence of family members, with most (77%) performing greater than 20. Subjects averaged 12.3 years of experience. The majority of urban and suburban providers felt it was inappropriate for family to witness resuscitations (75.9% versus 60.3%, respectively; p=0.068). Many providers reported feeling uncomfortable with family presence (31.5% urban versus 44.8% suburban; p=0.136), and few preferred that family witness the resuscitation (13.2% urban versus 15.4 suburban; p=0.738). A minority of providers believed that family were better prepared to accept the death of the patient (37.0% urban versus 37.6% suburban; p=0.939). Approximately half felt comfortable providing emotional support (66.0% urban versus 53.7% suburban; p=0.173). Many felt that family caused a negative impact during resuscitation (53.7% urban and 36.8% suburban; p=0.061). Urban providers more often reported feeling threatened by family members during resuscitation (66.7% versus 39.7%; p=0.003), and felt that family often interfered with their ability to perform resuscitations (35.6% versus 16.4%, p=0.014). CONCLUSIONS: EMS providers have substantial experience with family witnessed resuscitations, are uncomfortable about their presence, and often must provide support for families. While urban providers tended to report more negative experiences and perceptions, there were minimal differences between the two groups.     

A national survey of Turkish emergency physicians perspectives regarding family witnessed cardiopulmonary resuscitation

We investigated Turkish emergency physicians' views regarding family witnessed resuscitation (FWR) and to determine the current practice in Turkish academic emergency departments with regard to family members during resuscitation. A national cross-sectional, anonymous survey of emergency physicians working in academic emergency departments was conducted. Nineteen of the 23 university-based emergency medicine programs participated in the study. Two hundred and thirty-nine physicians completed the survey. Of the respondents, 83% did not endorse FWR. The most common reasons for not endorsing FWR was reported as higher stress levels of the resuscitation team and fear of causing physiological trauma to family members. Previous experience, previous knowledge in FWR, higher level of training and the acceptance of FWR in the institution where the participant works were associated with higher rates of FWR endorsement for this practice among emergency physicians.     

Personal Preferences Regarding Family Member Presence during Resuscitation

OBJECTIVES: Previous studies have shown that family members wish to be present during the resuscitation of a family member. No studies have addressed whether the patient would want family members present if he or she required resuscitation. The authors wanted to determine patients' preferences regarding family member presence during their own resuscitation. METHODS: A seven-item survey was administered to a sample of patients and their family members older than 17 years of age on six randomly chosen shifts in an academic community hospital emergency department. Responses were analyzed using chi-square and t-tests. Subjective comments were also recorded. RESULTS: A total of 266 subjects were asked to participate in the study; 200 subjects agreed to complete the survey. Most (72%) wanted a family member present. However, 21% did not wish any family member to be present. Positive responders (family present) tended to be younger (mean, 39.4 years; 95% confidence interval = 36.7 to 42.2) than negative responders (mean, 50.5 years; 95% confidence interval = 42.9 to 55.7; p < 0.001). Positive responders were also more likely to be nonwhite (chi2 = 6.29, p < 0.05). Gender, education, or health status was not associated with responder type. Of positive responders, 56% stated they wanted only certain members present, and these preferences were variable. CONCLUSIONS: Patients preferred to have family members present during their resuscitation. However, most of the positive responders wanted only certain members present, and approximately one in five patients, who tended to be older and white, did not want any family present. This study does not support an open policy of allowing family members into a resuscitation without prior knowledge of the patient's preferences.     

Family witnessed resuscitation: The views and preferences of recently resuscitated hospital inpatients, compared to matched controls without the experience of resuscitation survival

Aim of the study

To compare the preferences of patients who survived resuscitation with those admitted as emergency cases about whether family members should be present during resuscitation.

Methods

We used a case control design and recruited, from four large hospitals, 21 survivors of resuscitation and 40 patients admitted as emergency cases without the experience of resuscitation (control group) who were matched by age and gender at a ratio of 1:2. Data collection involved face-to-face interviews using a standardised 22 item questionnaire. Data analysis sought to identify differences between the two groups.

Results

Both groups were broadly supportive of the practice, however resuscitated patients were more likely to favour witnessing the resuscitation of a family member (72% versus 58%), preferred to have a relative present in the event they required resuscitation (67% versus 50%) and believed that relatives benefited from such an experience (67% versus 48%). Additionally, both groups indicated that staff should seek patient preferences about family witnessed resuscitation following hospital admission, and stated that they were unconcerned about confidential matters being discussed with family members present during resuscitation (91% and 75%, respectively). However none of these differences between the two groups achieved statistical significance.

Conclusion

Hospitalised patients report a favourable disposition towards family witnessed resuscitation, and this view appears to be strengthened by successfully surviving a resuscitation episode. Practitioners should strive to facilitate family witnessed resuscitation by establishing, documenting and enacting patient preferences. Research exploring the perceptions of the wider public would help further inform this debate.     

Benefits and pitfalls of family presence during resuscitation

The witnessing of resuscitation by a close family member is becoming increasingly common (Booth et al, 2004), yet the area remains under-researched. Findings from a limited number of studies show mixed feelings among health care staff about the benefits to the relative. However, family members who were present during the resuscitation attempt believed they had contributed in some way to the treatment. Health care providers should be aware of the benefits and pitfalls of family witnessed resuscitation (FWR) so they can make evidence-based decisions.     

Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest

CONTEXT: Advanced cardiac life support (ACLS) training was introduced to bring order and a systematic approach to the treatment of cardiac arrest by professional responders. In spite of the wide dissemination of ACLS training, it has been difficult to demonstrate improved outcome following such training. OBJECTIVE: To determine the value of formal ACLS training in improving survival from in-hospital cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS: A multi-center, prospective cohort study examined patient outcomes after resuscitation efforts by in-hospital rescue teams with and without ACLS-trained personnel. A total of 156 patients, experiencing 172 in-hospital cardiopulmonary arrest events over a 38-month period (January 1998 to March 2001) were studied. MAIN OUTCOME MEASURES: Primary endpoints included return of spontaneous circulation (ROSC), survival to hospital discharge, 30-day survival, and 1-year survival. RESULTS: The immediate success of resuscitation efforts for all patients was 39.7% (62/156). There was a significant increase in ROSC with ACLS-trained personnel (49/113; 43.4%) versus no ALCS-trained personnel (16/59; 27.1%; p=0.04). Likewise, patients treated by ACLS-trained personnel had increased survival to hospital discharge (26/82; 31.7% versus 7/34; 20.6%; p=0.23), significantly better 30-day survival (22/82; 26.8% versus 2/34; 5.9%; p<0.02), and significantly improved 1-year survival (18/82; 21.9% versus 0/34; 0%; p<0.002). CONCLUSION: The presence of at least one ACLS-trained team member at in-hospital resuscitation efforts increases both short and long-term survival following cardiac arrest.     

Family member presence during resuscitation in the emergency department: An Australian perspective

Objective: The practice of family member presence during resuscitation in the ED has attracted widespread attention over the last few decades. Despite the recommendations of international organizations, clinical staff remain reluctant to engage in this practice in many EDs. This paper separates the evidence from opinion to determine the current state of knowledge about this practice. Methods: A search strategy was developed and used to locate research based publications, which were subsequently reviewed for the strength of evidence providing the basis for recommendations. Results: The literature was examined to reveal what patients and their family members want; the outcomes of family presence during resuscitation for patients and their family members; staff views and practices regarding family presence during resuscitation. Findings suggest that providing the opportunity to be with their critically ill family member is both important to and beneficial for families, however, disparity in staff views has been identified as a major obstacle to family presence during resuscitation. Examination of published guidelines and staff practices described in the literature revealed consistent elements. Conclusion: Although critics point to the lack of rigour in this body of literature, the current state of knowledge suggests merit in pursuing future research to examine and measure effects of family member presence during resuscitation on patients, family members and healthcare providers.     

Comparison of hands-off time during CPR with manual and semi-automatic defibrillation in a manikin model

BACKGROUND: Rhythm analysis with current semi-automatic external defibrillators (AEDs) requires mandatory interruptions of chest compressions that may compromise the outcome after cardiopulmonary resuscitation (CPR). We hypothesised that interruptions would be shorter when the defibrillator was operated in manual mode by trained and certified ambulance personnel. MATERIALS AND METHODS: Sixteen pairs of ambulance personnel operated the defibrillator (Lifepak((R))12) in both semi-automatic (AED) and manual (MED) mode in a randomised, cross-over manikin CPR study, following the ERC 2000 Guidelines. RESULTS: Median time from last chest compression to shock delivery (with interquartile range) was 17s (13, 18) versus 11s (6, 15) (mean difference (95% CI) 6s (2, 10), p=0.004). Similarly, median time from shock delivery to resumed chest compressions was 25s (22, 26) versus 8s (7, 12) (median difference 13s, p=0.001) in the AED and MED groups, respectively. While sensitivity for identifying ventricular fibrillation (VF) in both modes and specificity in the AED mode were 100%, specificity was 89% in manual mode. Thus, some unwarranted shocks resulting in hands-off time (time without chest compressions) were given in manual mode. However, mean hands-off-ratio (time without chest compressions divided by total resuscitation time) was still lower, 0.2s (0.1, 0.3) versus 0.3s (0.28, 0.32) in manual mode, mean difference 0.10s (0.05, 0.15), p=0.001. CONCLUSION: Paramedics performed CPR with less hands-off time before and after shocks on a manikin with manual compared to semi-automatic defibrillation following the 2000 Guidelines. However, 12% of the shocks given manually were inappropriate.     

Survival from prehospital cardiac arrest is critically dependent upon response time

STUDY OBJECTIVE: This study correlated the delay in initiation of bystander cardiopulmonary resuscitation (ByCPR), basic (BLS) or advanced cardiac (ACLS) life support, and transport time (TT) to survival from prehospital cardiac arrest. This was a secondary endpoint in a study primarily evaluating the effect of bicarbonate on survival. DESIGN: Prospective multicenter trial. SETTING: Patients treated by urban, suburban, and rural emergency medical services (EMS) services. PATIENTS: Eight hundred and seventy-four prehospital cardiac arrest patients. INTERVENTIONS: This group underwent conventional ACLS intervention followed by empiric early administration of sodium bicarbonate noting resuscitation times. Survival was measured as the presence of vital signs on emergency department (ED) arrival. Data analysis utilized Student's t-test and logistic regression (p<0.05). RESULTS: Survival was improved with decreased time to BLS (5.52 min versus 6.81 min, p=0.047) and ACLS (7.29 min versus 9.49 min, p=0.002) intervention, as well as difference in time to return of spontaneous circulation (ROSC). The upper limit time interval after which no patient survived was 30 min for ACLS time, and 90 min for transport time. There was no overall difference in survival except at longer arrest times when considering the primary study intervention bicarbonate administration. CONCLUSION: Delay to the initiation of BLS and ACLS intervention influenced outcome from prehospital cardiac arrest negatively. There were no survivors after prolonged delay in initiation of ACLS of 30 min or greater or total resuscitation and transport time of 90 min. This result was not influenced by giving bicarbonate, the primary study intervention, except at longer arrest times.     

The influence of urban, suburban, or rural locale on survival from refractory prehospital cardiac arrest

There are many variables that can have an effect on survival in cardiopulmonary arrest. This study examined the effect of urban, suburban, or rural location on the outcome of prehospital cardiac arrest as a secondary end point in a study evaluating the effect of bicarbonate on survival. The proportion of survivors within a type of EMS provider system as well as response times were compared. This prospective, randomized, double-blind clinical intervention trial enrolled 874 prehospital cardiopulmonary arrest patients encountered by prehospital urban, suburban, and rural regional EMS area. Population density (patients per square mile) calculation allowed classification into urban (>2000/mi2), suburban (>400/mi2), and rural (0-399/mi2) systems. This group underwent standard advanced cardiac life support (ACLS) intervention with or without early empiric administration of bicarbonate in a 1-mEq/kg dose. A group of demographic, diagnostic, and therapeutic variables were analyzed for their effect on survival. Times were measured from collapse until onset of medical intervention and survival measured as the presence of ED vital signs on arrival. Data analysis used chi-squared with Pearson correlation for survivorship and Student t test comparisons for response times. The overall survival rate was approximately 13.9% (110 of 793), ranging from 9% rural, 14% for suburban, and 23% for urban sites for 372 patients (P=.007). Survival differences were associated with classification of arrest locale in this sample-best for urban, suburban, followed by rural sites. There was no difference in time to bystander cardiopulmonary resuscitation, but medical response time (basic life support) was decreased for suburban or urban sites, and intervention (ACLS) and transport times were decreased for suburban sites alone. Although response times were differentiated by location, they were not necessarily predictive of survival. Factors other than response time such as patient population or resuscitation skill could influence survival from cardiac arrest occurring in diverse prehospital service areas.     

Clinical Investigations

OBJECTIVE: To compare the frequencies with which suburban and urban parents give their children antibiotics without first consulting a physician. METHODS: This was a prospective, comparative survey of a suburban emergency department (ED) patient population in New Jersey with an annual patient census of 60,000 visits and an urban ED in Connecticut with 58,000 annual visits. A convenience sample of parents with children <18 years of age were enrolled. Patients who were critically ill and/or not oriented were excluded. Subjects provided written answers to a series of closed questions regarding their knowledge and use of antibiotics for their children over the previous 12 months. Categorical data were analyzed by chi-square and Fisher's exact test; continuous data were analyzed by t-tests. All tests were two-tailed with alpha set at 0.05. The primary endpoint, antibiotic "misuse," was defined as parental administration of antibiotics to a child during the previous 12 months without the consultation of a physician. RESULTS: Eight hundred one parents were enrolled; 424 at the suburban site. Parents in the suburban site were significantly different with regard to mean age (39 +/- 7.2 vs. 32 +/- 9.0, p < 0.001), percentage female sex (63% vs. 81%, p < 0.001), percentage white race (78% vs. 34%, p < 0.001), and percentage with private insurance (89% vs. 56%, p < 0.001). A higher percentage of parents at the suburban site had misused antibiotics (12.1% vs. 4.0%; p < 0.001). Using logistic regression, this significant difference in the rate of antibiotic misuse between the two groups remained after adjustment for demographic variables and insurance status of the parents (p < 0.001). Parents at the suburban site were significantly less likely to have been previously discharged with their child from an office or ED setting without antibiotics only to go soon afterwards to another health facility in order to obtain such medications (5% vs. 48%; p < 0.001). CONCLUSIONS: Parents in the suburban setting were more likely to have misused antibiotics for their children. On the other hand, parents in the urban setting were more likely to have been discharged by a physician at one health facility and gone to another physician's office or ED in order to obtain antibiotics for their children.     

Witnessed arrest, but not delayed bystander cardiopulmonary resuscitation improves prehospital cardiac arrest survival

Methods: This prospective, randomised, double blinded clinical intervention trial enrolled 874 prehospital cardiopulmonary arrest patients encountered in a prehospital urban, suburban, and rural regional emergency medical service (EMS) area. This group underwent conventional advanced cardiac life support intervention followed by empiric early administration of sodium bicarbonate (1 mEq/l), monitoring conventional resuscitation parameters. Survival was measured as presence of vital signs on emergency department (ED) arrival. Data were analysed using χ² with Pearson correlation and odds ratio where appropriate.

Results: The overall survival rate was 13.9% (110 of 792) of prehospital cardiac arrest patients. The mean (SD) time until provision of bystander cardiopulmonary resuscitation (ByCPR) by laymen was 2.08 (2.77) minutes, and basic life support (BLS) by emergency medical technicians was 6.62 (5.73) minutes. There was improved survival noted with witnessed cardiac arrest—a 2.2-fold increase in survival, 18.9% (76 of 402) versus 8.6% (27 of 315) compared with unwitnessed arrests (p<0.001) with a decreased risk ratio of mortality of 0.4534 (95% CI, 0.0857 to 0.1891). The presence of ByCPR occurred in 32% (228 of 716) of patients, but interestingly did not correlate with survival. The survival rate was 18.2% (33 of 181) if ByCPR was performed within two minutes and 12.8% (6 of 47), if performed >two minutes (p = 0.3752).

Conclusions: Survival after prehospital cardiac arrest is more likely when witnessed, but not necessarily when ByCPR was performed by laymen.

     

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations

Background: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration.

Objective: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations.

Methods/Design: We conducted a retrospective review of video recordings of pediatric patients who required critical care (“resuscitation”) in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained.

Results: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50?seconds [IQR 30,74] and 108?seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR.

Conclusion: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.     

Methodology-dependent Variation in Documentation of Outcome Predictors in Out-of-hospital Cardiac Arrest

Objective: To identify variation in outcome predictor documentation in out-of-hospital cardiac arrest associated with two different methods of data collection: concurrent questioning of personnel following a resuscitation attempt and archival report review.
Methods: All patients ≤ 18 years old who had had out-of-hospital cardiac arrests, verified using the New York City 911 telephone system, between October 1, 1990, and April 1, 1991, were eligible for inclusion. The authors reviewed the first 200 cases of presumed primary cardiac arrest involving a resuscitation attempt from among 3,243 consecutive ambulance call reports for cardiac arrest occurring during the study period. This archival data set was compared with data for the same 200 cases gathered through direct interview of field personnel by trained paramedics. The two data sets had been compiled independently by different individuals, using the same data collection instrument, which conformed to the Utstein template.
Results: Comparison of the data obtained from ambulance records with the data obtained from interviews of prehospital personnel revealed several areas of variance. Of note was a significantly lower proportion of bystander-witnessed ventricular fibrillation (VF) in the data set gathered from written reports (7% vs 18%; 95% CI for the difference 4–18%; p = 0.001).
Conclusion: Differences in methods of collection of out-of-hospital cardiac arrest data are associated with a more than twofold variation in the reported incidences of witnessed cardiac arrests manifesting as VF. Methodology-dependent variation in this important "denominator" may produce substantially different estimates of survival within the same cohort of patients.     

Post-Traumatic Stress Disorder Symptomology Associated with Witnessing Unsuccessful Out-of-hospital Cardiopulmonary Resuscitation

Objectives: The objective was to assess symptoms of post‐traumatic stress disorder (PTSD) associated with witnessing unsuccessful out‐of‐hospital cardiopulmonary resuscitation (CPR) on a family member. Methods: Adult family members of deceased, adult, nontraumatic out‐of‐hospital cardiac arrest victims who were transported to a large, Midwestern hospital were contacted by telephone beginning 1 month after the event. Subjects were dichotomized as to whether or not they were physically present during the patient’s resuscitation. A structured interview obtained the patient’s prearrest functioning, whether the family member witnessed or performed CPR, patient and family demographic data, key cardiac arrest events, and a measure of subject PTSD symptoms (PTSD Symptom Scale‐Interview [PSS‐I]). Results: There were 34 witnesses and 20 nonwitnesses. Each group was similar in race, religion, age, gender, and relationship to the patient. Patients in each group were similar in prearrest functioning. Witnesses’ total PTSD symptom scores were nearly two times higher than nonwitnesses (14.47 vs. 7.60, respectively; mean difference = 6.87, 95% confidence interval [CI] = 0.57 to 13.17). Two PSS‐I subscales were higher for witnesses than nonwitnesses: Avoidance (5.41 vs. 2.25; mean difference = 3.16, 95% CI = 0.74 to 5.58) and Increased Arousal (4.26 vs. 2.20; mean difference = 2.06, 95% CI = 0.08 to 4.05), while Reexperiencing was not (4.79 vs. 3.15; mean difference = 1.64, 95% CI = ?0.62 to 3.91). Linear regression analysis indicated that witnessing CPR of a loved one was associated with a mean increase of nearly 12 points on the PSS‐I after controlling for the possibility of other potentially influential events and characteristics. Results were similar when CPR providers (n = 6) were removed from the witness group. Conclusions: Witnessing a failed CPR attempt of a loved one in an out‐of‐hospital location may be associated with displaying symptoms of PTSD in the early term of the bereavement period. While preliminary, these data suggest that the relationship exists even after controlling for other potential factors that may also affect the propensity for displaying such symptoms, such as the suddenness and location of the patient’s cardiac arrest.     

A clinical observational study analysing the factors associated with hyperventilation during actual cardiopulmonary resuscitation in the emergency department

Aim

This is the first study to identify the factors associated with hyperventilation during actual cardiopulmonary resuscitation (CPR) in the emergency department (ED).

Methods

All CPR events in the ED were recorded by video from April 2011 to December 2011. The following variables were analysed using review of the recorded CPR data: ventilation rate (VR) during each minute and its associated factors including provider factors (experience, advanced cardiovascular life support (ACLS) certification), clinical factors (auscultation to confirm successful intubation, suctioning, and comments by the team leader) and time factors (time or day of CPR).

Results

Fifty-five adult CPR cases including a total of 673 min sectors were analysed. The higher rates of hyperventilation (VR > 10/min) were delivered by inexperienced (53.3% versus 14.2%) or uncertified ACLS provider (52.2% versus 10.8%), during night time (61.0 versus 34.5%) or weekend CPR (53.1% versus 35.6%) and when auscultation to confirm successful intubation was performed (93.5% versus 52.8%) than not (all p < 0.0001). However, experienced (25.3% versus 29.7%; p = 0.448) or certified ACLS provider (20.6% versus 31.3%; p < 0.0001) could not deliver high rate of proper ventilation (VR 8–10/min). Comment by the team leader was most strongly associated with the proper ventilation (odds ratio 7.035, 95% confidence interval 4.512–10.967).

Conclusions

Hyperventilation during CPR was associated with inexperienced or uncertified ACLS provider, auscultation to confirm intubation, and night time or weekend CPR. And to deliver proper ventilation, comments by the team leader should be given regardless of providers’ expert level.     

Emergency Department Do-not-attempt-resuscitation Orders: Next-of-kin Response to the Emergency Physician

Objective: To evaluate the response by families of incompetent, chronically debilitated, and/or terminally ill patients who were contacted for do-not-attempt-resuscitation (DNAR) status by an emergency physician (EP).
Methods: A prospective observational study was performed to assess next-of-kin willingness to support DNAR status for incompetent, chronically debilitated, and/or terminally ill patients. The families also were contacted by telephone follow-up 48–72 hours after the ED visit. Upon follow-up evaluation, the families were surveyed regarding prior DNAR instructions and their perceptions of the establishment of DNAR status in the ED. The study was conducted in an urban teaching hospital with an emergency medicine residency training program.
Results: Of the 71 patient families contacted, 60 (85%) of the patients had DNAR orders written in the ED. The families of these 60 patients had no negative response regarding contact by ED personnel. Of the
II (15%) patients whose families wished no DNAR order, only two families had negative responses to being contacted by the EP. In both cases the families had previously given detailed instructions to the chronic care facility.
Conclusion: The EP can play an important role in assisting the decision making process of families of incompetent, chronically debilitated, and/or terminally ill patients regarding institution of DNAR orders in the ED. Improved communication regarding existing DNAR orders with chronic care facilities might minimize the rare complaints received from families with preestablished DNAR orders.