| Interdisciplinary communication,clarity andconsistency |
Unequivocal,‘STOP’ sign |
Sense of direction/forward planning |
“basically made us question where we were going with the patient from the beginning.” (SPR) “It gives a plan; it makes the doctors do a plan for the patients so that you’re completely in the picture… as to who’s for resus, how far we’re going to go for active treatment, for escalation to ITU, that type of thing. And who isn’t for resus but they’re still for active treatment and are going to escalate, how far are we going to escalate” (Nurse) |
| Interdisciplinary communication,clarity andconsistency |
Arbitrary, ad hoc,only at crisis point |
Systematic |
“everyone has to have one, so it is thought about at the time of admission… before it was if someone suddenly becomes poorly and then you think ‘Oh, were they for resus?’ and then you realise they are and then there’s all a bit of a hoo–ha about trying to change that quite quickly” (Nurse) |
| Interdisciplinary communication,clarity andconsistency |
Marking out,‘special case’ |
Habitual, universal,routine |
“with the UFTO because everybody gets one you kind of get into the habit of constantly thinking about it for everyone” (Junior Doctor) |
| Interdisciplinarycommunication,clarity andconsistency |
Unofficial triage |
General clinicalsummary |
“If you’ve got all the information in one place rather than flicking through four weeks of admission… you know, that can only be a good thing for a patient.” (SPR) |
| Interdisciplinarycommunication,clarity andconsistency |
Insidious |
Open |
“it has been a long time now since somebody has asked me about somebody who wasn’t for resuscitation whether we should be actively treating them. Because it quite clearly says” (Consultant) |
| Patient dignityand respect |
Potentially negativeassociations forpatients/relatives |
Normalising forpatients/relatives |
“If you say everyone gets one it makes them feel better that it’s sort of part and parcel of coming in, and it’s not that we think they’re going to die” (Junior Doctor) |
| Patient dignityand respect |
Negativeassociationsfor clinicians |
Normalising forclinicians |
“now I think because everyone has the UFTO it’s more like they’re for treatment whether or not for resus” (Junior Doctor) |
| Patient dignityand respect |
Precipitatesevaluations offutility |
Encouragesevaluations ofappropriate actions |
“you know that there’s been a thought process, it’s not just some sort of arbitrary decision based upon the initial assessment of the patients’ chances” (Nurse) |
| Patient dignityand respect |
Clinical discomfortwith decision |
Clinical comfortwith decision |
“I do find it more comfortable that I can say for ward level of care, antibiotics and things, but not for CPR…” (Consultant) |
| Patient dignityand respect |
Stigma of formdiscouragesconversations withpatients andrelatives |
Makes clinicians morecomfortable in theirdiscussions withpatients and relatives |
“once you’ve explained it and you’ve shown them the form, they [a patient’s relatives] do feel happier.” (Junior Doctor) |
| Pragmatic details |
Recognisable inan emergency |
Recognisable inan emergency |
“it’s something that, the same as DNACPRs, it’s somewhere that’s easily accessible, you can find it… you can see things quite easily and quickly” (Registrar) |
| Pragmatic details |
Straightforward tocomplete – notdemanding on time |
Straightforward tocomplete – takes alittle time but savesmore time later on |
“you’re putting the effort in filling them in; so’s everybody else which makes your on–calls easier. Then, you know, that’s the kind of culture that perpetuates itself… it is more hard work filling in the forms, but it’s appropriate hard work. It’s not like it’s creating work, we should be considering DNACPR on all patients but it’s just not done.” (Registrar) |
| Pragmatic details |
Permanent recordof a single clinicaldecision |
Permanent recordof a range ofclinical decisions |
“it’s also good because DNARs, yeh that’s fine it kind of says ‘if this person’s heart stops beating we’re not, you know, going to resuscitate them’ but it doesn’t give any other sort of advice about ‘if this patient deteriorates massively what’s our ceiling of care?’ … Especially when you’re on call and you don’t necessarily know what has been happening with the patient and the limits of treatment are. So if you’ve got something like that to be able to say “right, ok, they wouldn’t go to ITU”, that’s helpful. ” (Junior Doctor) |
