Decision-making about likely prognosis and treatment limitations in patients after out of hospital cardiac arrest (OHCA) can be complex and challenging. Recent guidelines from both European and UK Resuscitation Councils offer useful recommendations about clinical assessment and parameters that support clinician decision-making.
In the critical care department at Doncaster Royal Infirmary a review (co-led by Consultant Nurse Lee Cutler and Dr Aaron Owen, Anaesthetic Registrar) of decision-making in patients after OHCA highlighted some inconsistencies. A quality improvement project aimed to standardise decision-making based on ERC & UKRC guidelines. A clinical pathway was integrated into the digital patient information system. The pathway included several validated clinical indicators. These included the Four score, NSE at 48 and 72 hours, seizure activity. Analysis of n=65 patients before (n=30) and after (n=35) the pathway implementation revealed that, in patients who did not survive, decision to withdraw treatment was undertaken on average 0.5 days earlier. In addition, in patients who did not survive a decision to withdraw was made in 91.4% of patients after pathway implementation versus 76.7% of patients before implementation.
The planned withdrawal of life support was a key quality improvement. Where patients die suddenly before withdrawal of treatment, loved ones have less opportunity to plan their time at bedside in the final hours. Death is more traumatic and distressing. An increase in planned withdrawal of treatment decisions gave greater opportunity for final hours of life planning and overall less distress for family and staff.
A final challenge which became evident was assessment of pupil reaction. This is undertaken as part of a clinical neurological assessment within the context of withdrawal of life support decision-making. Often the assessment is challenging because of patient factors, medication or environment. Clinical staff often lacked confidence in the assessment of pupil reactivity and inconsistent reactions were documented because of poor inter-rater reliability.
The final addition to the clinical pathway was the introduction of Pupillometry. Reporting the Neurological Pupil Index (NPI) greatly enhanced clinical assessment of some difficult to assess patients with suspected unsurvivable brain injury.
In this very challenging patient group a significant quality improvement was made through a digital clinical pathway incorporating published guidelines on the care of OHCA patients. In those who have unsurvivable brain injury the decision-making is supported by validated tools and leads to a more planned and compassionate end of life process.
Photo credit – Dr Lee R Cutler RN, BSc(Hons) MA(Ed) DMedSci, Consultant Nurse, Critical Care, Doncaster Royal Infirmary
