Documentation and Discussion Patterns of Cardiopulmonary Resuscitation Decisions in Frail Adults

Abstract Background With cardiac arrest, the probability of survival-to-discharge diminishes with increasing morbidity. Discussion and documentation of ceilings of care are essential, as advanced age should not disqualify patients from resuscitation attempts. We audited documentation and communication adherence as per our Hospital’s "Do Not Attempt Resuscitation" (DNAR) policy. Methods We prospectively reviewed records of inpatients aged ≥65y admitted to our 70 acute and 20 rehabilitation beds between August 2024 and January 2025. All had admissions ≥48 hours. Baseline patient characteristics and DNAR decision factors were collected. Temporal patterns and DNAR documentation were assessed at three time-points: ≤48h, between 48h and 7 days, and >7 days. Univariate logistic regression analysis was performed to identify factors associated with incomplete DNAR forms. Results Of 289 adults admitted to our wards, 48 had a DNAR form completed [70.8% female; median age: 85.5y; median clinical frailty scale: 6 (IQR: 5-7)]. Most common reasons for admission were falls and sepsis (41.6%). Within 48 hours of admission, 60.4% of DNAR decisions were recorded. Decisions were based on clinical judgement (45.8%) and patient preferences or advance directives (22.9%). Rationale was not documented in one-third. The clinical team signed and dated 97.9% of DNAR forms while nursing staff signed only 18 (37.5%). In 16.7% cases, communication to patients and/or relatives around the treatment escalation plan and DNAR decision was completed. Males (Odds ratio (OR): 2.24; 95% confidence interval (CI): 0.23-21.14), early-documentation (≤48h) of DNAR (OR: 3.6; 95% CI; 0.58-22.01), higher frailty (frailty scale ≥6) (OR: 4; (95% CI:0.65-24.54) were more likely to have incomplete documentation, yet statistically insignificant (P value > 0.05). Conclusion We found suboptimal documentation of important decisions around DNAR in a cohort with high comorbidity burden. Continuous education and compliance promotion of DNAR documentation on our wards is necessary.