Do-not-attempt-cardiopulmonary-resuscitation decisions : an evidence synthesis

Background: Cardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic. Aims and objectives: This project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice. Methods: A systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research. Results: The literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’. Limitations: The variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues. Conclusion: There is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care. Future work: Recommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication. Study registration: This study is registered as PROSPERO CRD42012002669. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Military healthcare system mitigates racial disparities for severe maternal morbidity from preeclampsiaAJOG Global Reports at a Glance

BACKGROUND: In the United States, Black women die at 2.5 times the rate of White women and 3.5 times the rate of Hispanic women. These racial health care disparities have been largely attributed to access to health care and other social determinants of health. OBJECTIVE: We hypothesize that the Military healthcare system models universal health care access seen in other developed countries and should equalize these rates. STUDY DESIGN: Delivery data from 41 Military treatment facilities across the Department of Defense (Army, Air Force, and Navy) including over 36,000 deliveries from 2019 to 2020 were compiled in a convenience dataset through the National Perinatal Information Center. After aggregation, the parameters of percent of deliveries complicated by Severe Maternal Morbidity and percent of severe maternal morbidity secondary to pre-eclampsia with and without transfusion were calculated. Risk ratios were calculated by race for the resulting summary data. American Indian/Alaska Native were excluded because of limited total number deliveries preventing statistical analyses. RESULTS: Overall, the risk of severe maternal morbidity was increased among Black women compared to White women. The risk of severe maternal morbidity related to pre-eclampsia showed no significant difference among races with or without transfusion. When other races were set as reference group, there was a significant difference for White women, suggesting a protective effect. CONCLUSION: Although women of color still experience overall severe maternal morbidity at higher rates than their White counterparts, TRICARE may have equalized the risk of severe maternal morbidity for deliveries complicated by pre-eclampsia

Increased maternal morbidity and mortality among Asian American and Pacific Islander women in the military health systemAJOG MFM at a Glance

BACKGROUND: Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare. OBJECTIVE: This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background. STUDY DESIGN: This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion. RESULTS: A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45–2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93–1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02–3.8) among Asian Pacific Islander women when compared with Black or White women. CONCLUSION: Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant

Highly electron rich β-diketiminato systems: Synthesis and coordination chemistry of amino functionalized 'N-nacnac' ligands

The synthesis of a class of electron-rich amino-functionalized β-diketiminato (N-nacnac) ligands is reported, with two synthetic methodologies having been developed for systems bearing backbone NMe2 or NEt2 groups and a range of N-bound aryl substituents. In contrast to their (Nacnac)H counterparts, the structures of the protio-ligands feature the bis(imine) tautomer and a backbone CH2 group. Direct metallation with lithium, magnesium or aluminium alkyls allows access to the respective metal complexes via deprotonation of the methylene function; in each case X-ray structures are consistent with a delocalized imino-amide ligand description. Trans-metallation using lithium N-nacnac complexes has then been exploited to access p and f-block metal complexes which allow for like-for-like benchmarking of the N-nacnac ligand family against their more familiar Nacnac counterparts. In the case of SnII the degree of electronic perturbation effected by introduction of the backbone NR2 groups appears to be constrained by the inability of the amino group to achieve effective conjugation with the N2C3 heterocycle. More obvious divergence from established structural norms are observed for complexes of the larger, harder YbII ion, with azaallyl/imino and even azaallyl/NMe2 coordination modes being demonstrated by X-ray crystallography

Highly Electron‐Rich β‐Diketiminato Systems: Synthesis and Coordination Chemistry of Amino‐Functionalized “ <i>N</i> ‐nacnac” Ligands

The synthesis of a class of electron-rich amino-functionalized β-diketiminato (N-nacnac) ligands is reported, with two synthetic methodologies having been developed for systems bearing backbone NMe2 or NEt2 groups and a range of N-bound aryl substituents. In contrast to their (Nacnac)H counterparts, the structures of the protio-ligands feature the bis(imine) tautomer and a backbone CH2 group. Direct metallation with lithium, magnesium or aluminium alkyls allows access to the respective metal complexes via deprotonation of the methylene function; in each case X-ray structures are consistent with a delocalized imino-amide ligand description. Trans-metallation using lithium N-nacnac complexes has then been exploited to access p and f-block metal complexes which allow for like-for-like benchmarking of the N-nacnac ligand family against their more familiar Nacnac counterparts. In the case of SnII the degree of electronic perturbation effected by introduction of the backbone NR2 groups appears to be constrained by the inability of the amino group to achieve effective conjugation with the N2C3 heterocycle. More obvious divergence from established structural norms are observed for complexes of the larger, harder YbII ion, with azaallyl/imino and even azaallyl/NMe2 coordination modes being demonstrated by X-ray crystallography

Highly electron rich β-diketiminato systems:synthesis and coordination chemistry of amino functionalized "<i>N</i>-nacnac" ligands

The synthesis of a class of electron-rich amino-functionalized β-diketiminato (N-nacnac) ligands is reported, with two synthetic methodologies having been developed for systems bearing backbone NMe2 or NEt2 groups and a range of N-bound aryl substituents. In contrast to their (Nacnac)H counterparts, the structures of the protio-ligands feature the bis(imine) tautomer and a backbone CH2 group. Direct metallation with lithium, magnesium or aluminium alkyls allows access to the respective metal complexes via deprotonation of the methylene function; in each case X-ray structures are consistent with a delocalized imino-amide ligand description. Trans-metallation using lithium N-nacnac complexes has then been exploited to access p and f-block metal complexes which allow for like-for-like benchmarking of the N-nacnac ligand family against their more familiar Nacnac counterparts. In the case of SnII the degree of electronic perturbation effected by introduction of the backbone NR2 groups appears to be constrained by the inability of the amino group to achieve effective conjugation with the N2C3 heterocycle. More obvious divergence from established structural norms are observed for complexes of the larger, harder YbII ion, with azaallyl/imino and even azaallyl/NMe2 coordination modes being demonstrated by X-ray crystallography