Abstract
To describe the involvement and input of physicians and nurses in cardiopulmonary resuscitation (CPR / do not attempt resuscitation (DNAR) decisions; to analyse decision patterns; and understand the practical implications. A Qualitative Grounded Theory study using one-time open-ended interviews with 40 volunteer physicians and 52 nurses drawn from acute care wards with mixes of heterogeneous cases in seven different hospitals in German-speaking Switzerland. Establishing DNAR orders in the best interests of patients was described as a challenging task requiring the leadership of senior physicians and nurses. Implicit decisions in favour of CPR predominated at the beginning of hospitalisation; depending on the context, they were relieved/superseded by explicit DNAR decisions. Explicit decisions were the result of hierarchical medical expertise, of multilateral interdisciplinary expertise, of patient autonomy and/or of negotiated patient autonomy. Each type of decision, implicit or explicit, potentially represented a team consensus. Non-consensual decisions were prone to precipitate personal or team conflicts, and, occasionally, led to non-compliance. Establishing DNAR orders is a demanding task. Reaching a consensus is of crucial importance in guaranteeing teamwork and good patient care. Communication and negotiation skills, professional and personal life experience and empathy for patients and colleagues are pivotal. Therefore, leadership by experienced senior physicians and nurses is needed and great efforts should be made with regard to multidisciplinary education.
Highlights
Since the 1980s, “do-not-attempt-resuscitation (DNAR)” orders have become common in medical practice
Phase 1: The implicit decision The implicit decision is regulated by institutional rules, generally representing institutional orders in favour of cardiopulmonary resuscitation (CPR) and rarely tailored to the specific situation of individual patients
It’s my obligation to make people aware of this possibility. Whether it can happen or not depends on the physician.”. To our knowledge this is the first study to analyse the decision-making process pertaining to CPR/DNAR orders and to explore the views of nurses and physicians who work in various acute care settings [27]
Summary
Since the 1980s, “do-not-attempt-resuscitation (DNAR)” orders have become common in medical practice. DNAR orders apply to only 19% of hospitalised patients in Italy, but to as many as 83% in Sweden and 86% in Switzerland [1, 2]. In Switzerland, the Swiss Academy of Medical Sciences very recently published guidelines on how DNAR decisions should be made and how patients and of kin should be involved in the decision-making process [12]. These current guidelines advocate explicit discussion of DNAR orders with all competent patients and/or their relatives, unless there is an obvious reason why this would not be in the patient’s best interests.
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