Discussions about Escalation and DNACPR in the Acute Oncology Service: a Quality Improvement Project


Session type:

Rebecca Squires1,Joseph Page1,Katherine Belfield1,Jason Chai1,Esther Hindley1
1University Hospitals Bristol NHS Foundation Trust



Although successful outcomes following in-hospital cardiopulmonary resuscitation (CPR) have improved over the past decade, CPR administered to patients with advanced malignancy continues to confer little beneficial outcome and ultimately prolongs the dying process1,2,3. Oncology patients are regularly confronted with the decision to choose between continued active cancer treatment and best supportive care4. To know the most appropriate time to discuss CPR is difficult for both the patient and clinician. However, early and open dialogue is frequently reported as a practical solution to improving the decision-making process5,6.


The primary aim of our project was to ensure that all patients admitted to the Oncology ward had an appropriate CPR decision established. Secondary aims included having an appropriate DNACPR discussion within 48 hours of admission, and having a DNACPR decision countersigned by a Consultant Oncologist within 48 hours of being made. All CPR decisions were audited at baseline and monthly thereafter. Interventions were established into 3 distinct themes: changing culture within the department, staff education, and changing systems and protocols. Decisions were deemed “inappropriate” based on treatment intent, prognosis and functional status.


At baseline, 35% (6/17) of patients did not have an appropriate DNACPR decision. None of the DNACPR decisions has been countersigned by a Consultant Oncologist. Following implementation of our interventions, by the fourth cycle, all patients had appropriate DNACPR decisions. 54% of DNACPR decisions had been countersigned by consultants. Median time to put the DNACPR decision in place was one day. These changes endured so that on the fifth cycle - when there was changeover of ward doctors - only 4% of patients did not have an appropriate DNACPR decision.


Changing culture within a department, educating staff and implementing systematic changes can foster dialogue regarding this sensitive and important issue and allow appropriate decisions regarding CPR to be made in collaboration with patients.