Treatment limitations and participation in elderly patients – the gap between medical-ethical guidelines and clinical practice : a cross sectional-study from Sweden
Hessulf, Fredrik ; Juhlin-Dannfelt, Matts ; Agvall, Björn LU
; Bremer, Anders
and Andersson, Viveka
(2025)
In BMC Geriatrics
25(1).
- Abstract
Background: Decision-making regarding treatment limitations such as “Do not attempt resuscitation” (DNAR) orders for older patients has been found deficient. Patients ≥ 80 years with substantial comorbidity have little chance of surviving cardiac arrest, thus require thorough risk classification focusing on comorbidity and frailty. This study aimed to explore the degree of frailty, comorbidity and treatment limitations in patients ≥ 80 years in various forms of care. Additionally, the study examined the extent to which patients and/or relatives participated in these decisions. Methods: Descriptive, quantitative cross-sectional design. Medical records of 500 patients ≥ 80 years were reviewed: 100 medical, 100 orthopaedic and 100 surgical... (More)
Background: Decision-making regarding treatment limitations such as “Do not attempt resuscitation” (DNAR) orders for older patients has been found deficient. Patients ≥ 80 years with substantial comorbidity have little chance of surviving cardiac arrest, thus require thorough risk classification focusing on comorbidity and frailty. This study aimed to explore the degree of frailty, comorbidity and treatment limitations in patients ≥ 80 years in various forms of care. Additionally, the study examined the extent to which patients and/or relatives participated in these decisions. Methods: Descriptive, quantitative cross-sectional design. Medical records of 500 patients ≥ 80 years were reviewed: 100 medical, 100 orthopaedic and 100 surgical in-patients, in addition to 100 patients in Home Health Services (HHS) and 100 patients in Municipal Short-Term Care (MSTC). Comorbidity was classified and categorized using the Age-combined Charlson Comorbidity Index (ACCI). Frailty was assessed using the Clinical Frailty Scale (CFS). DNAR decisions as well as other treatment and care limitations were compiled. Patients’ and relatives’ participation in discussions and information about treatment limitations was also examined. Results: Of the 500 patients, 48% had a moderate (5–7 points) and 50% a severe burden (≥ 8 points) of ACCI, while 91% were rated as frail (CFS ≥ 5). In total, 176/500 (35%) had valid DNAR-decisions. Both age ≥ 90 years (OR 4.07, 95% CI 2.56–6.37) and CFS ≥ 5 (OR 16.13, 95% CI 4.54–103.40) was significantly associated with a DNAR-decision, while ACCI ≥ 8 was not. Less than a third (29%) of patients with a DNAR-decision had been informed by a physician. For those without a DNAR-decision, there was no documentation of discussions regarding their wish for full cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Of all 500 patients, 14% had a discussion with a physician about CPR. Conclusion: Fewer treatment limitations than expected were documented for older, frail patients with moderate or severe comorbidity. Considerable deficiencies were found regarding decision-making and actively reviewing and confirming DNAR-decisions, showing a gap between medical-ethical guidelines and their application in practice. Improved adherence to medical-ethical guidelines would strengthen patients’ legal rights and their opportunity for shared decision-making.
(Less)
- author
- Hessulf, Fredrik
; Juhlin-Dannfelt, Matts
; Agvall, Björn
LU
; Bremer, Anders
and Andersson, Viveka
- organization
- publishing date
- 2025-12
- type
- Contribution to journal
- publication status
- published
- subject
- keywords
- Aged, Cardiopulmonary resuscitation, Comorbidity, Ethics, Frailty, Resuscitation orders, Treatment limitation
- in
- BMC Geriatrics
- volume
- 25
- issue
- 1
- article number
- 841
- publisher
- BioMed Central (BMC)
- external identifiers
-
- pmid:41188727
- scopus:105020881130
- ISSN
- 1471-2318
- DOI
- 10.1186/s12877-025-06552-x
- language
- English
- LU publication?
- yes
- id
- 8fd8457e-d8a4-44e4-8fe9-ed7e7e92ad64
- date added to LUP
- 2025-12-12 15:01:37
- date last changed
- 2026-01-09 18:09:10
@article{8fd8457e-d8a4-44e4-8fe9-ed7e7e92ad64,
abstract = {{<p>Background: Decision-making regarding treatment limitations such as “Do not attempt resuscitation” (DNAR) orders for older patients has been found deficient. Patients ≥ 80 years with substantial comorbidity have little chance of surviving cardiac arrest, thus require thorough risk classification focusing on comorbidity and frailty. This study aimed to explore the degree of frailty, comorbidity and treatment limitations in patients ≥ 80 years in various forms of care. Additionally, the study examined the extent to which patients and/or relatives participated in these decisions. Methods: Descriptive, quantitative cross-sectional design. Medical records of 500 patients ≥ 80 years were reviewed: 100 medical, 100 orthopaedic and 100 surgical in-patients, in addition to 100 patients in Home Health Services (HHS) and 100 patients in Municipal Short-Term Care (MSTC). Comorbidity was classified and categorized using the Age-combined Charlson Comorbidity Index (ACCI). Frailty was assessed using the Clinical Frailty Scale (CFS). DNAR decisions as well as other treatment and care limitations were compiled. Patients’ and relatives’ participation in discussions and information about treatment limitations was also examined. Results: Of the 500 patients, 48% had a moderate (5–7 points) and 50% a severe burden (≥ 8 points) of ACCI, while 91% were rated as frail (CFS ≥ 5). In total, 176/500 (35%) had valid DNAR-decisions. Both age ≥ 90 years (OR 4.07, 95% CI 2.56–6.37) and CFS ≥ 5 (OR 16.13, 95% CI 4.54–103.40) was significantly associated with a DNAR-decision, while ACCI ≥ 8 was not. Less than a third (29%) of patients with a DNAR-decision had been informed by a physician. For those without a DNAR-decision, there was no documentation of discussions regarding their wish for full cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Of all 500 patients, 14% had a discussion with a physician about CPR. Conclusion: Fewer treatment limitations than expected were documented for older, frail patients with moderate or severe comorbidity. Considerable deficiencies were found regarding decision-making and actively reviewing and confirming DNAR-decisions, showing a gap between medical-ethical guidelines and their application in practice. Improved adherence to medical-ethical guidelines would strengthen patients’ legal rights and their opportunity for shared decision-making.</p>}},
author = {{Hessulf, Fredrik and Juhlin-Dannfelt, Matts and Agvall, Björn and Bremer, Anders and Andersson, Viveka}},
issn = {{1471-2318}},
keywords = {{Aged; Cardiopulmonary resuscitation; Comorbidity; Ethics; Frailty; Resuscitation orders; Treatment limitation}},
language = {{eng}},
number = {{1}},
publisher = {{BioMed Central (BMC)}},
series = {{BMC Geriatrics}},
title = {{Treatment limitations and participation in elderly patients – the gap between medical-ethical guidelines and clinical practice : a cross sectional-study from Sweden}},
url = {{http://dx.doi.org/10.1186/s12877-025-06552-x}},
doi = {{10.1186/s12877-025-06552-x}},
volume = {{25}},
year = {{2025}},
}