Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice
Open accessAbstract
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.
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In a recent study of a mixed patient population in the UK 2017-2020, hospital mortality was in line with our study, with 32% hospital mortality for all patients with a Treatment Escalation and Limitation (TEAL) form, out of which 89% had DNACPR decisions.
“In a recent study of a mixed patient population in the UK 2017–2020, hospital mortality was in line with our study, with 32% hospital mortality for all patients with a Treatment Escalation and Limitation (TEAL) form, out of which 89% had DNACPR decisions.27”
From Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions in patients admitted through the emergency department in a Swedish University Hospital – An observational study of outcome, patient characteristics and changes in DNACPR decisions (2022) · cites this paper as [27]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredColeman et al. examined records of DNACPR decisions at a single centre from 2017 to 2020 and showed an increased rate of DNACPR use during pandemic, with patients tending to be younger and have fewer comorbidities.
“Coleman et al.27 examined records of DNACPR decisions at a single centre from 2017 to 2020 and showed an increased rate of DNACPR use during pandemic, with patients tending to be younger and have fewer comorbidities.”
Coleman et al reported DNACPR decisions recorded and Khalaileh identified DNACPR orders in nursing notes.
“Coleman et al24 reported DNACPR decisions recorded and Khalaileh60 identified DNACPR orders in nursing notes.”
From Do not attempt cardiopulmonary resuscitation decision-making process: scoping review (2025) · cites this paper as [24]
Data supports the idea that clinicians followed the recommendations to initiate treatment limitation conversations.
“and data supports the idea that clinicians followed the recommendations to initiate treatment limitation conversations.24”
From Do not attempt cardiopulmonary resuscitation decision-making process: scoping review (2025) · cites this paper as [24]
DNACPR discussions were reported to occur in the emergency department, during the admission period, after admission, within 48 hours of admission, within 72 hours of admission, or following admission secondary to a life-limiting illness.
“Discussions were held in the emergency department,21 admission period,22 23 after admission,24 within 48 hours of admission,25 within 72 hours of admission26 or following admission secondary to their life-limiting illness.27”
From Do not attempt cardiopulmonary resuscitation decision-making process: scoping review (2025) · cites this paper as [24]
The citation is attached to the claim that DNACPR discussions occurred in the emergency department. The Introduction and Discussion describe conversations with inpatients and during patient admissions, but the passages found when searching for emergency-department discussions do not say those discussions took place in the emergency department. No page numbers were available in our copy. (LLM, conf=0.72)
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Cites
Shared decision making: A model for clinical practice
Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rollnick, S., et al. (2012) · Journal of General Internal Medicine · doi:10.1007/s11606-012-2077-6 · Cited by 4,405 · cited 1× · see citing works
“Shared decision making is a concept that has grown in popularity in recent times.(15) Discussions around ceilings of care should involve patients where possible, and people should be included in decisions about their care.”
Nolan, J. P., Soar, J., Smith, G. B., Gwinnutt, C., Parrott, F., Power, S., Harrison, D. A., Nixon, E., & Rowan, K. (2014) · Resuscitation · doi:10.1016/j.resuscitation.2014.04.002 · Cited by 526 · see citing works
A survey of key opinion leaders on ethical resuscitation practices in 31 European Countries
Mentzelopoulos, S. D., Bossaert, L., Raffay, V., Askitopoulou, H., Perkins, G. D., Greif, R., Haywood, K., Van de Voorde, P., & Xanthos, T. (2016) · Resuscitation · doi:10.1016/j.resuscitation.2015.12.010 · Cited by 48 · see citing works
Flagged first, then by citations
Research works printed but not linked: 10
- [2]Grunau B. Reynolds J.C. Scheuermeyer F.X. Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: informing minimum durations of resuscitation Resuscitation 101 2016 50 56 26851705
- [3]Findlay Gp Shotton H. Kelly K. Mason M. Time to intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest National confidential enquiry into patient outcome and death 2012
- [4]Beauchamp T. Childress J. Principles of biomedical ethics 8 ed 2019 Oxford University Press
- [5]Buschmann C.T. Tsokos M. Frequent and rare complications of resuscitation attempts Intensive Care Med 35 2009 397 404 18807013
- [8]Shao F. Xu S. Ma X. In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China Resuscitation 151 2020 18 23 32283117 PMC7151543
- [10]National Institute for Health and Care Excellence COVID-19 rapid guideline: critical care in adults [updated 29/04/2020; cited 30/04/2020]. NICE Guideline (NG159)]. Available from: 2020 https://www.nice.org.uk/guidance/ng159/chapter/4-Clinical-decision-making 33497153
- [13]Johnson M. Whyte M. Loveridge R. Yorke R. Naleem S. A unified electronic tool for CPR and emergency treatment escalation plans improves communication and early collaborative decision making for acute hospital admissions BMJ Qual Improv Rep 6 2017 u213254.w216626 PMC5411716 28469900
- [14]Nightingale P.G. Adu D. Richards N.T. Peters M. Implementation of rules based computerised bedside prescribing and administration: intervention study BMJ 320 2000 750 753 10720357 PMC27317
- [17]Iacobucci G. Covid-19: doctors still at “considerable risk” from lack of PPE, BMA warns BMJ 2020 m1316 32234713
- [18]Nolan J. Soar J. Eikeland H. The chain of survival Resuscitation 71 2006 270 271 17070646
Cited by
Sorted by citations
Sutton, L., Goodacre, S., Thomas, B., & Connelly, S. (2021) · Resuscitation · doi:10.1016/j.resuscitation.2021.04.028 · Cited by 27 · see citing works
Recommended summary plan for emergency care and treatment: ReSPECT a mixed-methods study
Perkins, G. D., Hawkes, C. A., Eli, K., Griffin, J., Jacques, C., Huxley, C. J., Couper, K., Ochieng, C., Fuld, J., Fritz, Z., et al. (2022) · Health and Social Care Delivery Research · doi:10.3310/lfpe3627 · Cited by 16 · see citing works
Self-citationCode status documentation at admission in COVID-19 patients: a descriptive cohort study
Briedé, S., van Goor, H. M. R., de Hond, T. A. P., van Roeden, S. E., Staats, J. M., Oosterheert, J. J., van den Bos, F., & Kaasjager, K. A. H. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-050268 · Cited by 10 · see citing works
Piscator, E., Göransson, K., Forsberg, S., Herlitz, J., & Djärv, T. (2022) · Resuscitation Plus · doi:10.1016/j.resplu.2022.100209 · Cited by 10 · see citing works
Do not attempt cardiopulmonary resuscitation decision-making process: scoping review
Doody, O., Davidson, H., & Lombard, J. (2025) · BMJ Supportive & Palliative Care · doi:10.1136/spcare-2023-004573 · Cited by 10 · see citing works
“24 However, ethical attitudes toward DNACPR decision-making reflect hospital policy regarding prioritisation of autonomy over best interests, 52 and resources such as ethics consultation should be used.”
Jacobson, E., Troost, J. P., Epler, K., Lenhan, B., Rodgers, L., O'Callaghan, T., Painter, N., & Barrett, J. (2023) · Journal of Palliative Medicine · doi:10.1089/jpm.2022.0578 · Cited by 4 · see citing works
- Authors
- Coleman, J. J., Botkai, A., Marson, E. J., Evison, F., Atia, J., Wang, J., Gallier, S., Speakman, J., & Pankhurst, T.
- Affiliations
- University Hospitals Birmingham NHS Foundation Trust (GB)
- Corresponding author
- Coleman, Jamie J.
- Venue
- Resuscitation
- Publisher
- Elsevier BV
- Published
- 2020-10
- Volume
- 155
- Pages
- 172-179
- ISSN
- 0300-9572 (ISSN-L)
- PMC
- PMC7438269
- OpenAlex
- W3070445843
- Cited by
- 39
- References
- 3
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 6 · 2023: 7 · 2022: 10 · 2021: 12 · 2020: 2
- FWCI
- 5.81
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Resuscitation (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
- Funders
- University of Birmingham
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Ethics and Legal Issues in Pediatric Healthcare
- Keywords
- DNACPR, COVID-19 pandemic, treatment limitations, end-of-life decisions, shared decision-making, life-sustaining treatment, comfort care, patient preferences, benefit-harm balance
- MeSH terms
- Clinical Decision-Making, COVID-19, Aged, Delivery of Health Care, Female, United Kingdom, Hospitals, Teaching, Humans, Male, Middle Aged, Pneumonia, Viral, Retrospective Studies, Cohort Studies, Incidence, Databases, Factual, Resuscitation Orders, Critical Illness, Cardiopulmonary Resuscitation, Hospital Mortality, Coronavirus Infections, Pandemics
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