Do-not-resuscitate Discussion Research Articles

Ireland is Above European Average for do-not-Resuscitate Decision Making and Training: A Europe-Wide Survey On Resuscitation Decision Making Practices

Abstract Background Resuscitation success rates for older patients are poor. Research has shown that, despite many older people expressing a wish for full resuscitation initially, when the poor prognosis and outcomes are explained, this number drops substantially. One existing study, which did not include Ireland, revealed that a wide gap exists across European countries for rates of resuscitation discussions and the implementation of do-not-resuscitate (DNR) orders. The aim of this survey is to assess differences and barriers between European countries among doctors working in the field of geriatric medicine for DNR decision making. Methods An online survey was carried out among doctors working in geriatric medicine in European countries. Besides age, sex, years of experience and country of practice, sixteen questions regarding DNR discussion in terms of the frequency and confidence in doing it, prevalence of DNR discussions and possible barriers to this practice regarding DNR discussions were asked. Data analysis was carried out using R. Results In total, 473 respondents from 22 European countries completed the survey. Participants’ mean age was 41.8 years (standard deviation [SD] 9.9) and 64.9% were females. The mean number of years’ experience working as a doctor was 15.39 years (SD 9.62). 45 respondents were based in Ireland (9.5%). 95.5% of those in Ireland responded agree or strongly agree to feeling confident discussing DNR orders, in comparison to 79.7% of the total survey population. 73.4% of respondents in Ireland reported getting training in DNR discussions, versus 61.6% of the pan-European population. 86.7% of respondents in Ireland felt DNR orders are well accepted in their country, compared to 55% of total respondents. Conclusion This survey presents intra-European differences regarding practice of discussing DNR orders by doctors working in the field of geriatric medicine. Ireland was above average for discussing DNR orders, training received, and reported higher acceptability to society at large.

Discussion of the do-not-resuscitate (DNR) orders with the family caregivers of cancer patients: An example from a major cancer center in Saudi Arabia.

To explore the views of the family caregivers (FCGs) about the "do-not-resuscitate" (DNR) discussions and decision-making processes that occurred during hospitalization in a Saudi cancer center. In this cross-sectional survey, the FCGs of inpatients with advanced cancer completed a self-administered questionnaire soon after giving the patients a DNR status designation by their oncologists. Eighty-two FCGs participated in the study, with a median age of 36.5 years and male preponderance (70.7%). The FCGs were mostly sons (41.5%), daughters (14%), or brothers (11%) of patients. Only 13.4% of mentally competent patients had the chance to listen to the DNR discussion. The discussion mainly occurred in the ward corridor (48.8%) or another room away from the patients' rooms (35.4%). In 36.6% of cases, the discussion took ≤5 minutes. Half of the FCGs stated that the oncologists' justifications for the DNR decision were unconvincing. The majority (84.2%) of the FCGs felt that the healthcare providers should share the DNR decision-making with patients (1.2%), families (69.5%), or both (13.4%). FCGs ≤ 30 years of age were more supportive of giving patients' families a chance to participate in the DNR decision-making process (p = 0.012). There is considerable room for improving the current practice of DNR discussions and decision-making processes in the studied setting. A readily feasible rectifying measure is to ensure the adequacy of time and privacy when planning for DNR discussions. We expect our findings to draw the attention of stakeholders to a compelling need for reviewing the current policies and processes, aiming to improve the experience of cancer patients and their FCGs.

Advance care planning (ACP) to promote receipt of value-concordant care: Results vary according to patient priorities.

Benefits of advance care planning (ACP) have recently been questioned by experts, but ACP is comprised of discrete activities. Little is known about which, if any, ACP activities are associated with patients' greater likelihood of receiving value-concordant end-of-life (EoL) care. To determine which ACP activities [Do-Not-Resuscitate (DNR) order completion, designation of a healthcare proxy (HCP), and/or EoL discussions with physicians], individually and in combination, are associated with the greatest likelihood of receiving value-concordant care, and how results may vary based on patient-reported EoL care priorities. Data from 2 federally-funded, multisite, prospective cohort studies of EoL cancer care from 2002-2019 were analyzed. Cancer patients (N = 278) with metastatic disease refractory to chemotherapy were interviewed for a baseline assessment and followed prospectively until death. Interviews regarding patient priorities occurred a median of 111 days prior to death; data regarding EoL medical care were collected post-mortem from caregiver interviews and medical record abstraction. Patients who 1) prioritized life-extending care, and then received life-extending care (or avoided hospice care), or 2) prioritized comfort-focused care, and then avoided life-extending care (or received hospice care) in the last week of life, were coded as receiving value-concordant care. After inverse propensity score weighting, the ACP combination associated with the largest proportion of patients receiving value-concordant care was DNR, HCP, and EoL discussions (87% vs. 64% for no ACP activities; OR = 3.91, p = 0.006). In weighted analyses examining each ACP activity individually, DNR orders were associated with decreased likelihood of life-extending care (89% vs. 75%; p = 0.005) and EoL discussions were associated with increased likelihood of hospice care (77% vs. 55%; p = 0.002) among patients prioritizing comfort. ACP activities were not significantly associated with increased likelihood of receiving value-concordant care among patients prioritizing life-extension. For patients who prioritize comfort, EoL discussions with physicians and completion of DNR orders may improve odds of receiving value-concordant EoL care. For patients who prioritize life-extension, ACP does not appear to improve odds of receiving value-concordant EoL care.

IN HOSPITALIZED PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATORS: DOCUMENTED CODE STATUS DISCUSSIONS INFREQUENTLY REFERENCE THE IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR (ICD) DEVICE

IN HOSPITALIZED PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATORS: DOCUMENTED CODE STATUS DISCUSSIONS INFREQUENTLY REFERENCE THE IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR (ICD) DEVICE

The differences in nurses' willingness to discuss palliative care with patients and their family members.

This study aimed to evaluate the differences in nurses' willingness to discuss palliative care with terminally ill patients and their family members. The participants were randomly recruited from registered staff nurses ≥20 years of age who were responsible for clinical inpatient care in a tertiary hospital in northern Taiwan. A semi-structured questionnaire was administered to evaluate nurses' experiences of discussing do-not-resuscitate (DNR) decisions and their willingness to discuss palliative care with terminal patients and their family members. The differences in nurses' experiences regarding DNR and willingness to discuss palliative care with terminally ill patients and their family members were compared using the Chi-square test. Logistic regressions were used to analyze factors associated with nurses' willingness to discuss palliative care with patients and their families. More participants had experienced initiating discussions about DNR with patients' families than with patients (72.2% vs 61.9%, p < 0.001). Unadjusted logistic regression analysis showed that the experiences of actively initiating DNR discussions with patients were a significant factor associated with palliative care discussion with patients (odds ratio [OR] = 2.91, 95% confidence interval [CI]: 1.09-7.79). On the other hand, the experiences of actively initiating DNR discussions with patients and with patients' families were significant factors associated with palliative care discussion with patients' families (OR = 3.84, 95% CI: 1.22-12.06 and OR = 3.60, 95% CI: 1.19-10.90, respectively). After adjusting for covariates, no significant factors were found to be independently associated with nurses' willingness to discuss palliative care with patients and their family members. There are significant differences in nurses' willingness to discuss palliative care with patients and their family members. Further research is needed to evaluate factors associated with nurses' willingness to discuss palliative care with patients and their families to facilitate these discussions and protect patients' autonomy.

WE SPEAK FOR DNR

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: In 1960, Kouwenhoven and colleagues first introduced cardiopulmonary resuscitation (CPR). The decision for a Do Not Resuscitate(DNR) order should be based on a competent patient’s preference or the previously stated advance directive of a patient who is incompetent. Considering the medical ethics of nonmaleficence, the decision to withhold CPR can be justified when the intervention will not benefit the patient. The competence, comfort and familiarity of physicians in addressing DNR orders and other end of life decisions is important for management of patients with terminal illness, as successful end-of-life communication between patients and physicians is associated with superior psychosocial outcomes, less intensive treatment, greater patient satisfaction, and a higher likelihood of death at home. METHODS: The study analyzing the perception of DNR orders amongst physicians from Critical care and Internal Medicine department from a New York community hospital residency/ fellowship training program. The study used a cross-sectional 18-question anonymous online survey about DNR order which was distributed to physicians using surveymoney.com over a span of 5 weeks. RESULTS: Of the 99 completed surveys, 95% of the physicians had performed or taken part in obtaining DNR orders for patients, but only 10% had made a DNR decision for a significant other. Most physicians participating in the DNR discussion were in the initial phases of their medical careers with almost 58%physicians having graduated in the last 5yrs. The lack of personal experience may make these crucial discussions more difficult. 84% survey takers stated that they would like to be DNR themselves with the most important factor to choose DNR being imminent death. CONCLUSIONS: Patients typically rely on physicians to initiate conversations about end-of-life directives, and most seriously ill hospitalized patients prefer to make end-of-life decisions with physician advice. Given our results, we believe that most physicians base their discussion regarding end of life care and advance directive on learned principles and not on experience. In addition the younger physicians who do not have life experience may be unable to empathize with the older population, making the discussion regarding advance directives a mechanical process. This lack of life experience may be overcome with sensitivity training and role play to help alleviate the discomfort associated with such discussions. CLINICAL IMPLICATIONS: Ability to participate in goals of care discussion is an important skill to be honed by physicians in both inpatient and outpatient setting for ensuring appropriate management of patients in accordance with their value. The lack of training in such discussion can lead to a lack of guidance for the patients in settings of terminal illness and inappropriate use of healthcare resources. DISCLOSURES: No relevant relationships by Chetana Pendkar, source=Web Response

Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation.

Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.

The Concerns and Experience of Decision-Making Regarding Do-Not-Resuscitate Orders Among Caregivers in Hospice Palliative Care.

A do-not-resuscitate (DNR) order is an important end-of-life decision. In Taiwan, family caregivers are also involved in this decision-making process. This study aimed to explore the concerns and experiences regarding DNR decisions among caregivers in Taiwan. Qualitative study was conducted. Convenience sampling was used, and 26 caregivers were recruited whose patients had a DNR order and had received hospice care or hospice home care. Semi-structured interviews were used for data collection, including the previous experiences of DNR discussions with the patients and medical staff and their concerns and difficulties in decision-making. The data analysis was based on the principle of thematic analysis. Four themes were identified: (1) Patients: The caregivers respected the patients' willingness and did not want to make them feel like "giving up." (2) Caregivers' self: They did not want to intensify the patients' suffering but sometimes found it emotionally difficult to accept death. (3) Other family members: They were concerned about the other family members' opinions on DNR orders, their blame, and their views on filial impiety. (4) Medical staff: The information and suggestions from the medical staff were foundational to their decision-making. The caregivers needed the health care professionals' supports to deal with the concerns from patients and other family members as well as their emotional reactions.

Cancer patients, physicians, and nurses differ in their attitudes toward the decisional role in do-not-resuscitate decision-making.

Do-not-resuscitate (DNR) decision-making in severely ill patients presents many difficult medical, ethical, and legal challenges. The primary aim of this study was to explore cancer patients' and health care professionals' attitudes regarding DNR decision-making authority and timing of the decision. This study was a questionnaire survey among Danish cancer patients and their attending physicians and nurses in an oncology outpatient setting. Potential differences between patients', physicians', and nurses' answers to the questionnaire were analyzed using Fisher's exact test. Responses from 904 patients, 59 physicians, and 160 nurses were analyzed. The majority in all three groups agreed that DNR decisions should be made in collaboration between physician and patient. However, one-third of the patients answered that the patient alone should make the decision regarding DNR, which contrasts with the physicians' and nurses' attitudes, 0% and 6% pointing to the patient as sole decision-maker, respectively. In case of disagreement between patient and physician, a majority of both patients (66%) and physicians (86%) suggested themselves as the ultimate decision-maker. Additionally, 43% of patients but only 19% of physicians preferred the DNR discussion being brought up early in the course of the disease. With regard to the decisional role of patient vs. physician and the timing of the DNR discussion, we found a substantial discrepancy between the attitudes of cancer patients and physicians. This discrepancy calls for a greater awareness and discussion of this sensitive topic among both health care professionals and the public.

Nurses' Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study.

This study aimed to evaluate nurses’ experiences and factors related to their attitudes regarding discussions of do-not-resuscitate (DNR) and withdrawal of life-sustaining treatment (LST) with patients and their families. A cross-sectional survey was conducted in a tertiary hospital in Taiwan. Nurses aged ≥ 20 years who were in charge of acute inpatient care were randomly recruited. A semi-structured questionnaire was used to evaluate participants’ experiences and attitudes regarding discussions of DNR and LST withdrawal for terminal patients. Logistic regression with adjustment for covariates was used to analyze factors related to participants’ attitudes toward discussions about DNR and LST withdrawal with patients and families in the future care of terminal patients. The participants were 132 nurses. They had significantly more discussions about DNR and LST withdrawal with patients’ families than with patients. Regression analysis showed that participants who had past experiences in actively initiating DNR discussions with patients or patients’ families were significantly more likely to discuss DNR with patients in the future care of terminal patients, but participants aged 40.0 to 60.0 years were significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experiences of actively initiated DNR or LST discussions with patients’ families were significantly more likely to discuss DNR with patients’ families, but those aged 40.0 to 60.0 years were also significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experience in actively initiating discussions about LST withdrawal with patients’ families, being male, and possessing an education level higher than university were significantly related to LST withdrawal discussions with terminal patients or their families in the future. In conclusion, there need to be more discussions about DNR and LST withdrawal with patients. To protect patients’ autonomy and their rights to make decisions about their DNR and LST, measures are needed to facilitate DNR and LST discussions with patients to ensure better end-of-life care.

The Concept of Do Not Resuscitate for Students in King Abdulaziz University Hospital.

Introduction:Do not resuscitate (DNR) is a medical procedure for patients who are suffering from critical, untreatable, and irreversible disease where the patient's life is predicted to end. DNR is considered a sensitive decision for patients and their relatives, as well as physicians.Aim:This study is aimed to assess the knowledge and attitude of medical students and interns toward the DNR order and the factors affecting their attitude at the King Abdulaziz University Hospital (KAUH) in Jeddah.Methods:Nonintervention cross-sectional study was conducted among 429 medical students (preclinical and clinical years) and interns who were given an online questionnaire between May and June in 2016 at KAUH in 18 Kingdom of Saudi Arabia.Results:Our study indicates that most of the participants (73.2%) were familiar with DNR order; however, more than half of them (58.3%) did not take any lecture or session on DNR. Large proportion of medical students had the opinion that attending a lecture or session on DNR would help them discuss it more skillfully with the patients and their relatives. More than half of the participants (55%) believed that there is a Fatwa that regulates DNR on the Islamic level.Conclusion:Participants, who were interns, were more familiar with the term DNR, whereas the 2nd-year medical students were less familiar with DNR. Considering the variation in the knowledge of participants about DNR, we conclude that additional lectures and sessions about DNR should be added to the medical school curriculum to make the students more confident and able in handling the DNR discussions.

Knowledge and Attitude of ER and Intensive Care Unit Physicians toward Do-Not-Resuscitate in a Tertiary Care Center in Saudi Arabia: A Survey Study.

Introduction:Only a few studies from Arab Muslim countries address do-not-resuscitate (DNR) practice. The knowledge of physicians about the existing policy and the attitude towards DNR were surveyed.Objective:The objective of this study is to identify the knowledge of the participants of the local DNR policy and barriers of addressing DNR including religious background.Methods:A questionnaire has been distributed to Emergency Room (ER) and Intensive Care Unit (ICU) physicians.Results:A total of 112 physicians mostly Muslims (97.3%). About 108 (96.4%) were aware about the existence of DNR policy in our institute. 107 (95.5%) stated that DNR is not against Islamic. Only (13.4%) of the physicians have advance directives and (90.2%) answered they will request to be DNR if they have terminal illness. Lack of patients and families understanding (51.8%) and inadequate training (35.7%) were the two most important barriers for effective DNR discussion. Patients and families level of education (58.0%) and cultural factors (52.7%) were the main obstacles in initiating a DNR order.Conclusions:There is a lack of knowledge about DNR policy which makes the optimization of DNR process difficult. Most physicians wish DNR for themselves and their patients at the end of life, but only a few of them have advance directives. The most important barriers for initializing and discussing DNR were lack of patient understanding, level of education, and the culture of patients. Most of the Muslim physicians believe that DNR is not against Islamic rules. We suggest that the DNR concept should be a part of any training program.

Do-not-resuscitate orders and high-risk pediatric surgery: professional nuisance or medical necessity?

BackgroundThere is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, although invasive procedures are frequently performed in very high risk and critically ill children. Despite significant efforts in adult medicine to enhance discussions around end-of-life care, little is known about similar endeavors in the pediatric population. MethodsA retrospective review of the National Surgical Quality Improvement Program Pediatric database was performed. Patients aged <18 y with American Society of Anesthesiologists class 3 or greater who underwent elective surgical procedure in 2012-2013 were included. Demographic factors, principal diagnosis, associated conditions, DNR status, and mortality were extracted. Descriptive analysis was performed. ResultsA total of 20,164 patients met the inclusion criteria. Only 36 (0.2%) patients had a signed DNR order before surgical procedure. Of severely ill American Society of Anesthesiologists four patients, only 1% had DNR status. There were no differences in gender, race, ethnicity, or surgical specialty by the presence of a DNR order. Notably, 17.1% of children who died within this period had multiple surgical procedures performed before expiring. ConclusionsThe rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even among severely ill children. Well-informed end-of-life care discussions in a patient-focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of DNR discussion will also allow better tracking and benchmarking.

Medical Residents’ Practices and Perceptions toward Do-Not-Resuscitate (DNR) Order

The knowledge and implementation skills of the DNR order amongst physicians in training appear to be quite variable. Few studies had assessed residents' views on this complex topic. Our objective was to describe the medical residents’ practices and perceptions toward DNR order. A 26 question survey was distributed to medical residents during the academic day activity. Only 56 residents completed the questionnaire (75% response rate). 61.40% of the residents understood the definition of DNR order. 85.96% thought physicians shouldn’t order diagnostic tests for DNR patients and 92.98% thought physicians shouldn’t give blood products and antibiotics to DNR patients. 45.61% thought DNR order would lead to poor care. 36.84% thought physician alone should decide about the DNR decision. 45.61% answered that DNR order never discussed with patients. 64.91% answered that consultant discussed DNR order with patients. 42.11% of residents were involved in the discussion of DNR order. 66.67% answered that time to decide about the DNR order on day of admission. 42.11% answered there was variation between consultants regarding the care of DNR patient. 43.86% answered there was variation in the clinical care before and after DNR order was placed. 87.72% thought here was a need for formal training in DNR discussion. 68.42% didn’t know if KFSH and RC had clinical guidelines for DNR patients care. Conclusion: (1) Majority of the residents had misunderstanding regarding DNR patient care and comfortable care. There is a need for developing a structured residency program curriculum to address resident skills in end-oflife care. (2) Encouraged discussions DNR issues in the outpatient setting could prevent unwanted resuscitation in the acute setting. (3) Efforts are needed to increase patients and their families’ awareness about the meaning of DNR order. (4) There is a need to unify and improve quality of care provided to DNR patients by developing specific strategies within a framework of goals of care.

Translating into Practice Cancer Patients' Views on Do-Not-Resuscitate Decision-Making.

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.

Do-not-resuscitate orders and related factors among family surrogates of patients in the emergency department.

The purpose of this study was to investigate the prevalence of do-not-resuscitate (DNR) orders and to identify relevant factors influencing the DNR decision-making process by patients' surrogates in the emergency department (ED). A prospective, descriptive, and correlational research design was adopted. A total of 200 surrogates of cancer or non-cancer terminal patients, regardless of whether they signed a DNR order, were recruited as subjects after physicians of the emergency department explained the patient's conditions, advised on withholding medical treatment, and provided information on palliative care to all surrogates. Of the 200 surrogates, 23 % signed a DNR order for the patients. The demographic characteristics of patients and surrogates, the level of understanding of DNR orders, and factors of the DNR decision had no significant influence on the DNR decision. However, greater severity of disease (odds ratio (OR) = 1.38; 95 % confidence interval (CI) = 0.95-1.74), physician's initiative in discussing with the families (OR = 1.42; 95 % CI = 1.21-1.84), and longer length of hospital stay (OR = 1.06; 95 % CI = 1.03-1.08) were contributing factors affecting patient surrogates' DNR decisions. The findings of this study indicated that surrogates of patients who were more severe in disease condition, whose physicians initiated the discussion of palliative care, and who stayed longer in hospital were important factors affecting the surrogates' DNR decision-making. Therefore, early initiation of DNR discussions is suggested to improve end-of-life care.

How, When and Where to Discuss Do Not Resuscitate: A Prospective Study to Compare the Perceptions and Preferences of Patients, Caregivers, and Health Care Providers in a Multidisciplinary Lung Cancer Clinic

Background: Do Not Resuscitate (DNR) is a significant but challenging part of end-of-life discussions when dealing with incurable lung cancer patients. We have explored the perceptions and preferences of patients, their caregivers (CGs), and health care providers (HCPs) and the current practice and opinions on DNR discussions in a multidisciplinary lung cancer clinic. Materials and Methods: This is a prospective descriptive study with a mixed quantitative and qualitative methodology to capture perceptions of the participants. To obtain a rich description of participant responses to questionnaire items, we employed a ‘think aloud’ process that prompted participants to immediately verbalize their thoughts when responding to questionnaire items. We used content analysis and constant comparison techniques to identify, code and categorize primary themes in the captured data. Results: Ten patients with advanced-stage lung cancer; nine CGs from the lung clinic and ten HCPs from the Thoracic Disease Site Group (DSG) were enrolled in the study. Most patients had only a limited understanding of DNR. Most CGs had a fair to good understanding of DNR. Most HCPs perceived their patients to have understood DNR most of the time. When patients were interviewed, a theme of “anticipated discussion” about DNR was identified. Patients and CGs expressed having faith in the system and responsible physicians as to when to discuss DNR. HCPs embraced a clinician preference-based decision-making approach to engaging in DNR discussions. They desired more resources, more knowledge, more structure and more time to discuss DNR. Most HCPs felt that it would be worth conducting a prospective clinical trial to determine the best time to discuss DNR. Conclusions: This pilot study provides a unique mixed quantitative and qualitative understanding of the perceptions of patients with lung cancer and their CGs and HCPs regarding DNR discussion. Our findings will help further the development of evidence-based guidelines and a broad prospective study that would have important implications for policies and practices around DNR discussions in order to reduce the emotional pain of dying patients, their CGs and HCPs.

Perceptions and Preferences of Patients with Terminal Lung Cancer and Family Caregivers about DNR.

Background: Patients with terminal lung cancer and their families are challenged and stressed with the end of life discussions. Do Not Resuscitate (DNR) orders are a critical part of such discussions.Objective: To understand the perceptions and preferences of patients with terminal lung cancer and their family caregivers around DNR discussions. .Methods: Our quantitative component consisted of a pen-and-paper questionnaire that was followed by a ‘think aloud’ process to capture perceptions of participants in response to questionnaire items. Qualitative methods included content analysis and constant comparison techniques to identify, code, and categorize primary themes arising from ‘think aloud’ responses.Results: In this pilot study, 10 patients with advanced stage lung cancer and nine family caregivers were enrolled from one tertiary cancer care centre. Three major themes and several sub-themes were identified reflecting participants’ psychosocial environment, emotional responses to DNR discussions, and suggestions to improve DNR discussions. Most of the time, both patients and caregivers perceived a supportive environment within their family unit. Some patients were uncertain about their disease extent but most had entertained thoughts about prognosis and DNR status prior to having a discussion with their physician. A range of situations stimulated the DNR discussion. Most patients were uncertain about identifying the most appropriate health care provider (HCP) for DNR discussion. While participants found DNR discussions distressing, patients maintained hope in the face of accepting a terminal diagnosis. There were mixed feelings about the reversibility of a DNR decision and concerns about the care of the patients after being stated as DNR. Participants desired their HCP to be emotionally sensitive, knowledgeable, respectful, and straightforward.Conclusions: Most participants were open about their experiences with psychosocial supports and emotional reactions and made suggestions to HCP to improve DNR discussions. Further examination in larger longitudinal studies is required to validate the observations in the current study.

Internal medicine residents' perspectives and practice about do not resuscitate orders: survey analysis in the western region of Saudi Arabia.

BackgroundThe purpose of this study was to analyze the perceptions and practices of internal medicine residents in the western region of Saudi Arabia regarding the implementation of do not resuscitate (DNR) orders to improve future training practices among physicians.MethodsMedical residents involved in training programs in the western region of Saudi Arabia, including Jeddah, Makah, Medinah, and Taif, were invited to participate in a cross-sectional, anonymous, online survey regarding DNR orders. The 16-question survey was distributed to residents in all training programs in the region using surveymonkey.com, and the results were collected and tabulated.ResultsOf 364 residents, 157 completed the questionnaire, resulting in a 43% response rate. The study showed that most (66%) internal medicine residents in the western region of Saudi Arabia participate in DNR discussions with patients and family or surrogate decision-makers. In addition, 43% were observed by faculty members, and half of them (51.9%) reported feeling comfortable during these discussions. Furthermore, most residents believed that additional educational programs would enhance their competence in addressing issues related to DNR discussions.ConclusionThis study highlights the need for a structured curriculum to teach skills relating to end-of-life issues such as DNR orders to residents in the Saudi Arabian medical system. The majority of residents surveyed believe they would benefit from additional training in DNR discussions. Therefore, an evidence-based curriculum providing instruction for improving discussions regarding DNR orders would improve physician confidence and effectiveness in caring for critically ill patients.

How, When and Where to Discuss Do Not Resuscitate: A Prospective Study to Compare the Perceptions and Preferences of Patients, Caregivers, and Health Care Providers in a Multidisciplinary Lung Cancer Clinic.

Background: Do Not Resuscitate (DNR) is a significant but challenging part of end-of-life discussions when dealing with incurable lung cancer patients. We have explored the perceptions and preferences of patients, their caregivers (CGs), and health care providers (HCPs) and the current practice and opinions on DNR discussions in a multidisciplinary lung cancer clinic.Materials and Methods: This is a prospective descriptive study with a mixed quantitative and qualitative methodology to capture perceptions of the participants. To obtain a rich description of participant responses to questionnaire items, we employed a ‘think aloud’ process that prompted participants to immediately verbalize their thoughts when responding to questionnaire items. We used content analysis and constant comparison techniques to identify, code and categorize primary themes in the captured data.Results: Ten patients with advanced-stage lung cancer; nine CGs from the lung clinic and ten HCPs from the Thoracic Disease Site Group (DSG) were enrolled in the study. Most patients had only a limited understanding of DNR. Most CGs had a fair to good understanding of DNR. Most HCPs perceived their patients to have understood DNR most of the time. When patients were interviewed, a theme of “anticipated discussion” about DNR was identified. Patients and CGs expressed having faith in the system and responsible physicians as to when to discuss DNR. HCPs embraced a clinician preference-based decision-making approach to engaging in DNR discussions. They desired more resources, more knowledge, more structure and more time to discuss DNR. Most HCPs felt that it would be worth conducting a prospective clinical trial to determine the best time to discuss DNR.Conclusions: This pilot study provides a unique mixed quantitative and qualitative understanding of the perceptions of patients with lung cancer and their CGs and HCPs regarding DNR discussion. Our findings will help further the development of evidence-based guidelines and a broad prospective study that would have important implications for policies and practices around DNR discussions in order to reduce the emotional pain of dying patients, their CGs and HCPs.