Assuring do-not-resuscitate statements for frail elderly

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Introduction Resuscitation after a cardiac arrest is not always desired. The chance of survival with a good quality of life is very low for elderly with the age of 70+ outside the hospital. Every person has the right to decide whether to receive treatments, thus there is also a choice to decide to be resuscitated or not in case of a resuscitation situation. Besides a patient’s wish or choice to be not resuscitated, a physician can decide that it is medical futile to resuscitate a patient. The decision is called a Do-Not-Resuscitate decision, and is written down in a DNR statement. Next to written DNR statements, a DNR medal is legally accepted, both giving the possibility to communicate this DNR decision to bystanders or healthcare professionals in case of a resuscitation situation where the patient is unconscious. Despite these communication tools, people who decided and recorded for DNR, can be unjustified resuscitated. Bringing someone to life with possible bad quality of life, is a very emotional burden for family, the patient and healthcare professionals, and brings high costs for the hospital. The assignment For this reason, in this project a product is designed to assure the DNR statement for frail elderly. The focus is on resuscitation situations outside the hospital, and the stakeholders that are involved in the process of recording a DNR statement. The transfer of this information between healthcare professionals (and institutions) and between the patient and healthcare professionals in a resuscitation situation. The requirements A product is designed that assures DNR statements and that contains personal information including information about a life-or-death decision. This makes it highly important that all user groups trust the product, so they are able to trust and willing to use the product. A product that assures DNR statements must provide this information fast. In a resuscitation situation speed is highly important, because every second counts for the patient, to give him a chance to survive. In a resuscitation the first priority is to treat the patient, with no time to search for a DNR statement. Stakeholders To get insight in the interests of all stakeholders and the requirements for the designed product, next to literature research, several interviews and participatory research was performed. The four most important stakeholders for assuring the DNR statement, are frail elderly, physicians, ambulanace personnel and bystanders of a resuscitation situation. The ambulance personnel are the first healthcare professionals to arrive during a resuscitation situation outside the hospital, but they have no insight in a patient’s medical information. DNR statements are recorded and talks take place between frail elderly and physicians. Bystanders are the first person who are confronted with a patient having a cardiac arrest. The Heartbead system The Heartbead is a product that includes a RFID tag on which the DNR statement is recorded. The Heartbead is attached to the emergency response necklace of frail elderly, giving them a product that is not bothering their daily life. The Heartbead system is the total system including the Heartbead, which as a system is able to assure DNR statements of frail elderly (see figure 1). The system contains besides the Heartbead, the ambulance’s monitor, the physician’s minitor and reader, and the checkpoint. Physicians are able to read the information from the Heartbead with a RFID reader, and with the physician’s software new DNR information can be recorded at the Heartbead in a familiar way. The addition of a checkpoint at the physician’s office gives frail elderly the possibility to check the information that is recorded at the Heartbead. Ambulance personnel use a monitor during the resuscitation process to monitor the heart rhytm of a victim and if needed to apply electrical shocks to the victim’s body. This monitor with an integrated reader gives ambulance personnel the chance to read the DNR statement from the Heartbead. When the monitor is placed close to the victim, and the Heartbead is within the read range of the reader, the message is shown at the display of the monitor that a Heartbead is found and gives the legally required information about the victim. Evaluation The Heartbead system was evaluated with the main user groups; frail elderly, ambulance personnel and physicians. All user groups experienced the system as useful and were enthusiastic. The physicians liked the fact that the software to update the Heartbead was integrated in their current software, and the ambulance personnel did like the integrated reader in the monitor. Both design decisions did fit the healthcare professional’s workflow and contributed to trust the system. The eldelry did not clearly understand how the system worked, but their evaluation of the Heartbead itself was positive. Recommendations Further research is recommended to be done about the technology, and about the willingness of all technology and healthcare stakeholders to change the existing system. Also a reader integrated in an AED is recommended to make it possible for bystanders to read the Heartbead.