Purpose of the study
To characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation (CPR) including those who were pronounced dead at the hospital after out-of-hospital resuscitation. The main interest of the study was patient involvement in, documentation of, and compliance with previous decisions on resuscitation (Do not attempt to resuscitate orders; DNAR).   
Material and methods
All patients who died in or were pronounced dead in Kalmar County Hospital during January 1, 2016 until December 31, 2016 were included in this retrospective study. All pertinent information from the patients’ electronic chart was analyzed. The study was approved by the Regional Ethic review Board in Linköping, Sweden; 2017/270-31.
Results
Of 660 patients (mean age 77.7 ± 12.1 years; range 21-101; median 79; 321 (48.6%) female), a DNAR order had been documented in 563 patients (85.3%). In 66 of 94 (70.2%) patients without DNAR, CPR was unsuccessfully attempted. 28 of 94 (29.8%) patients died without attempt at CPR and without a DNAR order in place. In 4 of 561 (0.7%) patients CPR was attempted despite a DNAR order in place. During the same time, 19 patients survived in-hospital CPR, none of whom had a DNAR order. 
The time between DNAR documentation and death was between 0 and 2645 days (mean 26.7; median 4). Documentation had been done on admission in 93 cases (16.5%), during hospital stay in 312 cases (55.4%) or was from an earlier hospital stay in 86 patients (15.3%). An earlier order was confirmed ad admission in 40 cases (7.1%) while confirmation of earlier order was delayed until later during hospital stay in 35 cases (6.2%). In 416 patients (73.9%) the DNAR order had not been discussed with neither patient nor family/friends. Moreover, in 84 cases (14.9%) neither patient nor family/friends were even informed about the decision on code status. 
Conclusions
In general, a large percentage of patients in our study had a DNAR order in place (85.3%) and compliance with the order was high (99.3%). However, 28 patients (4.2%) died without CPR attempt or DNAR order. While guidelines require discussion of DNAR orders with the patient/surrogate, this had not been done in almost three fourths of the patients of this study. Further work has to be done to implement ethical CPR guidelines to insure patient autonomy.

5 - Usage of Do-not-attempt-to resuscitate-orders in a Swedish community hospital – patient involvement, documentation and compliance