48 and 49 Residents rated the education programme positively.48 and 49 Two studies assessed self-reported changes in comfort and/or confidence in discussing CPR decisions; Seoane et al. found house officers rated their self confidence in this area more highly at the end of a rotation which involved a specialised teaching component,47 while Kahn et al. found that participants reported significantly improved understanding of the legality of DNACPR decisions (but not in comfort of discussing them) after attending a workshop

with simulated patients centred on end-of-life Trametinib in vitro discussion skills.46 Two studies assessed changes in patients’ outcomes/experiences after training.44 and 45 Furman et al. found no change in the number of resuscitation discussions with patients on admission following a half-day training session (including role-playing exercises) for medical residents.44 Perron Junod et al. trained nine junior doctors on the meaning of and ethics surrounding DNACPR decisions in parallel with introducing a new DNACPR policy and form.45 The doctors self-reported performance in DNACPR decision making. The doctors reported better patient involvement and improved understanding of the scope of the DNACPR decisions post intervention.45 Five studies were identified.10, 15, this website 16, 50 and 51 Three studies addressed patient/surrogate education whilst two studies evaluated structured

communication with patients. Etomidate The overall quality assessment was weak for one study and moderate for four. In a large (n = 2517) before-and-after study, introduction of a patient information leaflet and provision of written information for doctors in a tertiary hospital in the Netherlands had no effect on the frequency of DNACPR documentation. 10 Showing a short video of CPR to relatives of patients in intensive care improved their knowledge about resuscitation but did not influence their preference about DNACPR

decisions. 50 Finally, in a randomised controlled cross over trial, cancer patient’s choice about whether they preferred to be asked about their opinion or informed of a DNACPR decision was unchanged after watching two short videos. 51 The main findings of this review were that although interest and research into DNACPR decisions has been increasing the overall quality of published studies was generally poor. Thematic synthesis identified key interventions which may improve DNACPR decision making. The most promising interventions provided some structure to the decision making process, by contextualising the resuscitation decision alongside overall treatment objectives. The deterioration of a patient or the need to talk about other treatments with them is often the trigger for discussions about CPR. This was evidenced by a recent systematic review of medical emergency team (MET) activations which reported that between 1.7% and 30.