Abstract
Do-not-resuscitate (DNR) orders are necessary if resuscitation, the default option in hospitals, should be avoided because a patient is known to be dying and attempted resuscitation would be inappropriate. To avoid inappropriate resuscitation at night, if no DNR order has been recorded, after-hours medical staff are often asked to have a DNR discussion with patients whose condition is deteriorating, but with whom they are unfamiliar. Participants in two qualitative studies of cancer patients’ views on how to present DNR discussions recognized that such patients are at different stages of understanding of their situation and may not be ready for a DNR discussion; therefore, a one-policy-fits-all approach was thought to be inappropriate. To formulate a policy that incorporates the patient’s views, we propose that a standard form which mandates a DNR discussion is replaced by a “blank sheet” with instructions to record the progress of the discussion with the patient, and a medical recommendation for a DNR decision to guide the nursing staff in case of a cardiac arrest. Such an advance care directive would have to honor specifically expressed patient or guardian wishes whilst allowing for flexibility, yet would direct nurses or other staff so that they can avoid inappropriate cardiopulmonary resuscitation of a patient dying of cancer.
Highlights
It is the evening nursing shift in a large urban hospital
Having performed two qualitative studies to ascertain the opinion of patients with cancer about their preferences for how and when DNR discussions occur, we sought to formulate policy based on that input and illustrate how it would translate into practice by using clinical scenarios [7,8]
We propose that the advance care directive be a “blank sheet” prominently placed in the case notes, prefaced by instructions for the medical staff about how to complete it in a variety of scenarios
Summary
A nurse notices that one of her elderly patients with metastatic cancer who is receiving palliative treatment has deteriorated over the 16 h since her last shift She consults the case records and discovers that there has been no do-not-resuscitate (DNR) order written on his chart. Nursing staff do not have the authority to override this even if, in their judgment, a resuscitation attempt would be inappropriate or futile This is distressing since a patient whose heart stops as part of natural dying of a disease such as cancer should be differentiated from one who suffers a sudden unexpected cardiac event [2]. Having performed two qualitative studies to ascertain the opinion of patients with cancer about their preferences for how and when DNR discussions occur, we sought to formulate policy based on that input and illustrate how it would translate into practice by using clinical scenarios [7,8]
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