DNR Decisions Research Articles

Do-Not-ResuscitateDecision-Making during the COVID-19 Pandemic in a Teaching Hospital: Lessons Learned for the Future.

A cross-sectional survey study was conducted between February 2021 and April 2021 for all doctors and doctors in training, working in the Antwerp University Hospital during the COVID-19 pandemic. 127 doctors participated in this study. The familiarity with the different scores used in the triage during the COVID-10 pandemic was 51% for the Clinical Frailty Scale (CFS) and 20% for the Charlson Comorbidity Index (CCI). Participants indicated that their DNR decision is based on various aspects such as clinical assessment, comorbidities, patient's wishes, age, prognosis, and functional state. The familiarity with the different scores used during triage assessments is low. The total clinical picture of the patient is needed to make a considered decision, and this total picture of the patient seems to be well encompassed by frailty measurement (CFS). Although many participants indicated that the different scores do not offer much added value compared to their clinical assessment, it can help guide DNR decisions, especially for doctors in training.

Factors affecting do-not-resuscitate decisions among patients with amyotrophic lateral sclerosis in Taiwan.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease. Usually, patients survive for approximately 2-4 years after the onset of the disease, and they often die of respiratory failure. This study examined the factors associated with signing a "do not resuscitate" (DNR) form in patients with ALS. This cross-sectional study included patients diagnosed with ALS between January 2015 and December 2019 in a Taipei City hospital. We recorded patients' age at disease onset; sex; presence of diabetes mellitus, hypertension, cancer, or depression; use of invasive positive pressure ventilator (IPPV) or non-IPPV (NIPPV); use of nasogastric tube (NG) or percutaneous endoscopic gastrostomy (PEG) tube; follow-up years; and number of hospitalizations. Data from 162 patients were recorded (99 men). Fifty-six (34.6%) signed a DNR. Multivariate logistic regression analyses revealed that the factors associated with DNR included NIPPV (OR = 6.95, 95% CI = 2.21-21.84), PEG tube feeding (OR = 2.86, 95% CI = 1.13-7.24), NG tube feeding (OR = 5.75, 95% CI = 1.77-18.65), follow-up years (OR = 1.13, 95% CI = 1.02-1.26), and number of hospital admissions (OR = 1.26, 95% CI = 1.02-1.57). The findings suggest that end-of-life decision making among patients with ALS may often be delayed. DNR decisions should be discussed with patients and their families during the early stages of disease progression. Physicians are advised to discuss DNR with patients when they can speak and to offer palliative care options.

Nurses’ Experience of Ethical Dilemma at the End-Of-Life Care in the Intensive Care Unit

One of the aims of the care service in the Intensive Care Unit (ICU) is to prepare patients in end-of-life conditions to die in a dignified manner. This can be challenging due to decision-making problems and result in a dilemma. Therefore, this study explores the ethical dilemmas experienced by nurses that provide end-of-life care in the ICU. The qualitative phenomenological methodology was used to describe the ethical dilemmas nurses face during these conditions. The data were collected through in-depth interviews and were analyzed using Colaizzi. Purposive sampling was used to select a total of eight participants, i.e., ICU nurses, who have treated end-of-life patients. Four themes were obtained from this study, namely, “the dilemma between the family’s decisions and continuing care”, “patient’s life expectancy and the family’s hope”, “DNR decisions and the nurse’s confidence”, and “the family’s understanding of the information provided”. This study recommends that the assessment of end-of-life status in critical care areas, especially the ICU, should be conducted as soon as possible to have a clearer purpose for the care provided.

Factors that impact the accuracy with which nurses place preterm infants with respiratory distress syndrome in the prone position.

Prone positioning is an important treatment procedure for preterm infants with Respiratory Distress Syndrome (RDS). However, the accuracy with which preterm infants in the Neonatal Intensive Care Unit (NICU) are placed in the prone position is impacted by several factors. The current study aimed to identify these factors. One hundred and twenty-eight nurses were included in this cross-sectional study. Direct observations of the research subjects were used to collect the research data. The participants completed a research questionnaire that included their demographic data and three others to obtain information on their clinical experience, knowledge of positioning, caring behaviors, and efficacy. Independent factors likely to affect preterm infant positioning were evaluated using multivariate logistic regression. The alpha level was set at 5%. Knowledge (p=0.002) and caring behavior (p=0.009) significantly influenced the accuracy with which nurses placed preterm infants with RDS in the prone position. Nursing efficacy, infant's bodyweight, gestational age, the institution, and DNR decisions did not significantly impact accuracy. NICU nursing staff require interventions to increase their knowledge of the accurate positioning of preterm infants with RDS.

Oncologist- versus hospitalist-led service: Differences in hospital utilization for solid tumor patients.

53 Background: Hospitalists have been practicing alongside oncologists to provide high quality care for hospitalized cancer patients. We examined the differences in hospital utilization and outcomes among solid tumor patients admitted to oncologist-led teams (OT) versus hospitalist-led teams (HT). Methods: We performed a retrospective cohort study of patients with solid tumors admitted to the OT or HT at Mount Sinai Hospital from July to December 2019. We excluded patients less than 18 years of age, primary hematologic malignancies, or admission to intensive care or surgical units. We used the Activity Measure for Post Acute Care (AMPAC) and Charlson Comorbidity Index as a measure of functional ability and illness severity, respectively. We performed bivariate and multivariate analyses comparing differences in length of stay, ICU transfers, palliative care consults, healthcare proxy (HCP) decision, new DNR decision, readmission within 30 days and inpatient mortality by type of admitting service (OT vs HT). Results: A total of 544 patients were identified; 61% (334) admitted to HT. There were significant differences according to race and cancer type (p= 0.001 for both). HT patients had more functional impairment (p<0.0001) and poorer prognosis (p=0.0002). In bivariate analysis, HT had significantly more ICU transfers (OT, 2% vs HT, 8%; p=0.008), new DNR decisions (OT, 7% vs HT, 16%; p=0.002), and inpatient mortality (OT, 4% vs HT, 9%; p=0.02) while OT had significantly more palliative care consults (OT, 45% vs HT, 20%; p<0.0001). Multivariate analysis (Table) demonstrates HT had significantly more new DNR decisions (odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.23-0.93) and OT had significantly more palliative care consults (OR: 4.01, 95% CI: 2.51-6.43). Conclusions: At our academic hospital, inpatient cancer care led by hospitalists is comparable to that of oncologists despite HT caring for more severely ill oncology patients. From a value perspective, hospitalists facilitating care for hospitalized cancer patients will allow oncologists to maximize ambulatory time and focus on active cancer treatment. [Table: see text]

Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision

BackgroundAs the “do not resuscitate” (DNR) discussion involves communication, this study explored (1) the effects of a title that included “allow natural death”, and of information contents and outcomes of the decision; and (2) the information needs and consideration of the DNR decision, and benefits and barriers of the DNR discussion.MethodsHealthy adults (n = 524) were presented with a scenario with different titles, information contents, and outcomes, and they rated the probability of a DNR decision. A questionnaire including information needs, consideration of the decision, and benefits and barriers of DNR discussion was also used.ResultsThere was a significantly higher probability of signing the DNR order when the title included “allow natural death” (t = − 4.51, p < 0.001), when comprehensive information was provided (F = 60.64, p < 0.001), and when there were worse outcomes (F = 292.16, p < 0.001). Common information needs included remaining life period and the prognosis. Common barriers were the families’ worries and uncertainty about future physical changes.ConclusionThe title, information contents, and outcomes may influence the DNR decisions. Health-care providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.

Ethical competence in DNR decisions \u2013a qualitative study of Swedish physicians and nurses working in hematology and oncology care

BackgroundDNR decisions are frequently made in oncology and hematology care and physicians and nurses may face related ethical dilemmas. Ethics is considered a basic competence in health care and can be understood as a capacity to handle a task that involves an ethical dilemma in an adequate, ethically responsible manner. One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action and knowledge. Ethical competence can be developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make, or be involved in, DNR decisions and how such skills can be learned and developed. A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions.MethodsIndividual interviews were conducted with fifteen nurses and sixteen physicians. The interviews were analyzed using thematic content analysis.ResultsPhysicians and nurses in the study reflected on their ethical competence in relation to DNR decisions, on what it should comprise and how it could be developed. The ethical competence described by the respondents related to the concepts being, doing and knowing.ConclusionsIn order to make ethically sound DNR decisions in oncology and hematology care, physicians and nurses need to develop appropriate virtues, improve their knowledge of ethical theories and relevant clinical guidelines. Ethical competence also includes the ability to act upon ethical judgements. Continued ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients in relation to DNR decisions, in their efforts to act in the best interest of the patient.

Non-Renal Hospice Eligibility in the Dialysis Population: Utilization and Barriers (S764)

retained 60% of their improvement at 6 months. All expressed increased comfort with opioid usage, communicating bad news, goals-of-care, and advanced directive discussions. Implications for Research, Policy, or Practice. Anesthesiologists are expected to be pain specialists. Improving knowledge and skill utilizing goals-of-care and non-invasive pain management may lead to improved care management of both acute and chronic pain. Further research will look at any changes in attitudes toward perioperative DNR decisions in those with and without palliative medicine rotations.

Outstanding ethico-legal-fiqhi issues

To examine the practical issues arising in implementation of DNR from the perspectives of maqasid al shari’at and qawa’id al shari’at . The purposes and principles of the Law provided a conceptual framework for analyzing practical issues related to DNR orders. The issues were identified from a Pubmed literature search with the key word ‘DNR’ covering about 30 years and were analyzed as they related to the principles of intention, certainty and preventing harm and also to the purposes of preserving life and resources. It is proposed that DNR orders be written for patients in an established death process, i.e. cardiorespiratory failure beyond Young’s point ‘ z ’. Patients with terminal incurable conditions who develop acute, reversible cardiorespiratory arrest should be resuscitated if the net benefit will last for a reasonable time. Five components of DNR (cardiopulmonary resuscitation involving chest compression and oxygenation, endotracheal intubation, mechanical ventilation, defibrillation and vasoactive or ionotropic medication) could be provided on a case-by-case basis. The interventions may or may not include renal dialysis, blood transfusion, parenteral nutrition, pulmonary hygiene and normal treatment such as antibiotics. All patients, irrespective of their DNR status, deserve supportive care. To improve DNR processes, training should be given on end-of-life ethical issues for physicians and nurses, DNR orders should specify interventions, the autonomy of physicians who have a conscientious objection to DNR should be respected, more psychosocial support should be given to the families of DNR patients, more empirical research is required on DNR, and DNR decisions should be audited regularly.

Link between decisions regarding resuscitation and preferences for quality over length of life with heart failure.

Survival preferences, ascertained from time-trade-off utilities, have not been studied in heart failure patients who designate a 'do not resuscitate' (DNR) status. Therefore, the aim of this study was to determine the association of heart failure patients' resuscitation preferences with survival preferences and mortality in the ESCAPE trial. We analysed the association of resuscitation orders at 1 month with time-trade-off utilities and 6-month mortality. There were 26 and 349 patients with a DNR order and Full Code order, respectively. DNR patients were older, had more coronary artery disease, hypertension, renal impairment, and poorer exercise capacity than Full Code patients. DNR patients also experienced longer hospitalization and higher 6-month mortality. In multivariate analysis, DNR preference was associated with 10-fold higher odds of willingness to trade survival time (lower time-trade-off utility) in favour of improved quality of life [odds ratio 10.33, 95% confidence interval (CI) 1.65-64.80]. DNR preference was the best predictor of mortality (χ(2) 26.12, P < 0.0001, hazard ratio 6.88, 95% CI 3.28-14.41), despite adjustment for known predictors including brain natriuretic peptide. Heart failure patients' requests to forego resuscitation may signify more than simply 'what-if' directives for emergency care. DNR decisions may reflect preferences for intervention to enhance quality rather than prolong survival, which is particularly important as these patients have high early mortality.

Autonomy and the Family as (In)Appropriate Surrogates for DNR Decisions: A Qualitative Analysis of Dying Cancer Patients’ Talk

Autonomy and the Family as (In)Appropriate Surrogates for DNR Decisions: A Qualitative Analysis of Dying Cancer Patients’ Talk

What Families Say about Surrogacy: A Response to “Autonomy and the Family as (In)appropriate Surrogates for DNR Decisions”

What Families Say about Surrogacy: A Response to “Autonomy and the Family as (In)appropriate Surrogates for DNR Decisions”

Survival and quality of life in burns

Advances in medical technology and practices have been associated with increasing medical specialization, but they have developed at a price. This price has included not only enormous financial costs, but the additional cost of dehumanized patient care, diminished confidence in the medical staff and, consequently, human suffering. Burn injuries are catastrophic in scope and require specialized, intensive and prolonged treatment from which ensure ethical and psychological problems often complicated by many individual factors. Some of them arising from the Code of Patients Rights not only in the Czech Republic and contribute to DNR decisions (do-not-resuscitate). Not only Quantity of life but also Quality of life should be considered, particularly in burns. Critical factor is age. In old patients more sophisticated medical knowledge and practice may actually contribute to suffering. At any age scarring represents a special type of disfigurement. The image is more likely to evoke public avoidance than sympathy. The non handicapped by their negative attitudes help create and perpetuate the handicap and the consequent burden of suffering in burn patients. Language: en

Ask the experts.

There is 'no one size fits all' solution to giving control to older people at the end of life. We need to move away from traditional homogenous and paternalistic approaches that see death as an event rather than part of the ageing process towards ensuring that individual wishes are foremost in CPR /DNR discussions. To achieve this, training and peer support is required as many staff, particularly those just entering a profession, feel unprepared to deal with issues around death and dying. Only when we have staff confident and competent to openly discuss and answer questions around CPR /DNR decisions will we truly be able to offer older people the opportunity to articulate and retain control over decisions at the end of their lives.

회복 불가능한 환자의 심폐소새술포기(DNR)와 관련된 윤리문제

The following research has examined ethical dilemmas regarding denial of resuscitation by patients. The articlealso suggests several proposals for optimized solutions. First of all, the history and nature of CPR &amp; DNR have been discussed. Second, mutual interactions during making decisions on DNR have been introduced. Because physicians do not exclusively conduct the decision on DNR, patients, family members, and other related siblings should be involved in the process. If necessary, the ethics committee may be applied for making appropriate decisions. Thirdly, in order to locate the nature of ethical dilemma on DNR decisions, the relationship between patients and physicians, full understanding the importance of CPR necessity, and defining the method of DNR would need to be well explained. Finally, through the ethical discussion on DNR, following conclusions have been suggested. In all situations, DNR must let physicians make decision on futility of CPR for patients' current or future conditions, and the decision must be made only after patients are fully aware of the consequences. Under the law of respecting patients' opinions, patients must have the ability to make decisions on DNR. The proper moments for deciding DNR should depend on behaviors regarding his/her conditions or diseases. Because a health care institution play an important role in making decisions as well, all opinions must be reviewed for the best outcome. It is important to remember that the main decision makers on DNR are patients. Following discussions have concluded that an agreement among people nationwide is quite essential for the appropriate DNR decisions. The research may serve as a supplement for the process of establishing the DNR guideline.

Analysis of the speech of dying patients with cancer on end-of-life decision making

8216 Background: Patients with cancer approaching the end of life were interviewed to ascertain their views on the formulation of “do not resuscitate” (DNR) orders to guide policy. Methods: Consecutive eligible patients had semi-structured interviews which were recorded, transcribed, and subjected to qualitative analysis. Accrual ended when data saturation occurred, that is no new issues were being raised. Results: Twenty-eight patients, 13 females, 15 males (average age 61, range 39–79) were interviewed, 86% as inpatients, half with family members or friends present. All were Australian residents with English as their first language; 64% were currently married. The patients spanned 11 different cancers from which 23 (82%) died within 12 weeks of interview, including 4 within 1 week, with the longest survivor just over 6 months. Fourteen patients had a DNR order recorded in their file at interview and only 1 had not clearly specified their wishes at time of death. However, for 7 patients there were discrepancies between their views at interview and what was recorded. All but 4 patients understood the term DNR. Resuscitation was often spoken of as a medical intervention which may stop an appropriate peaceful death. The majority believed that the patient should make the DNR decision stressing the importance of individual autonomy but some preferred a shared decision with physicians or family. Patients said that being lucid was necessary for making DNR decisions. There was no consensus on the appropriate timing of a DNR discussion. Some favored no discussion. A minority favored a discussion early before possible mental incapacity, but those who supported holding the discussion when the issue became pressing wanted to spare patients the negative emotions of an earlier discussion. There was ambivalence about who should decide when to discuss, some believing it to be the patient's decision but others deferring to the experience of the physician. Conclusions: DNR policies must allow the flexibility to accommodate diverse individual patient wishes. Documentation of DNR orders can be problematic, both in accurately ascertaining patients' wishes, and accommodating changes that may occur. No significant financial relationships to disclose.

Analysis of the speech of dying patients with cancer on end-of-life decision making

8216 Background: Patients with cancer approaching the end of life were interviewed to ascertain their views on the formulation of “do not resuscitate” (DNR) orders to guide policy. Methods: Consecutive eligible patients had semi-structured interviews which were recorded, transcribed, and subjected to qualitative analysis. Accrual ended when data saturation occurred, that is no new issues were being raised. Results: Twenty-eight patients, 13 females, 15 males (average age 61, range 39–79) were interviewed, 86% as inpatients, half with family members or friends present. All were Australian residents with English as their first language; 64% were currently married. The patients spanned 11 different cancers from which 23 (82%) died within 12 weeks of interview, including 4 within 1 week, with the longest survivor just over 6 months. Fourteen patients had a DNR order recorded in their file at interview and only 1 had not clearly specified their wishes at time of death. However, for 7 patients there were discrepancies between their views at interview and what was recorded. All but 4 patients understood the term DNR. Resuscitation was often spoken of as a medical intervention which may stop an appropriate peaceful death. The majority believed that the patient should make the DNR decision stressing the importance of individual autonomy but some preferred a shared decision with physicians or family. Patients said that being lucid was necessary for making DNR decisions. There was no consensus on the appropriate timing of a DNR discussion. Some favored no discussion. A minority favored a discussion early before possible mental incapacity, but those who supported holding the discussion when the issue became pressing wanted to spare patients the negative emotions of an earlier discussion. There was ambivalence about who should decide when to discuss, some believing it to be the patient's decision but others deferring to the experience of the physician. Conclusions: DNR policies must allow the flexibility to accommodate diverse individual patient wishes. Documentation of DNR orders can be problematic, both in accurately ascertaining patients' wishes, and accommodating changes that may occur. No significant financial relationships to disclose.

Comparison of medical and nursing attitudes to resuscitation and patient autonomy between a British and an American teaching hospital

In the last 30 years, cardiopulmonary resuscitation (CPR) has evolved from an intervention indicated only in cases of acute insult to an otherwise healthy body to a default measure employed in virtually all cases of cardiac failure. The high cost and low efficacy rate of CPR has provoked questions about the moral and economic wisdom of its routine use, particularly for elderly patients with serious comorbidity. This paper presents the results of a comparative study of decision making practices concerning “Do-Not-Resuscitate” (DNR) orders in British and American hospitals. Thirty-four physicians and nurses in one American and one British hospital were interviewed about their decision making practices. Qualitative methods of data analysis were employed. The study revealed that while the American and British hospitals had adopted similar formal protocols for DNR decision making, in practice the British physicians often made DNR decisions unilaterally, whereas the American physicians sought the patient's or surrogate's consent in every instance, even where it was not legally required. The British decision making model enables physicians to reduce the inappropriate use of resuscitation, but at the expense of patient autonomy. In contrast, the American approach fully respects patient autonomy, but except in cases of medical futility grants physicians no authority to refuse to render treatments that are in their judgment contraindicated.

Beyond DNR

In this issue of Neurology, Alexandrov et al [1] make a useful contribution to the literature by describing acute stroke patients for whom DNR decisions were made. They found that of 450 patients with acute stroke, DNR orders were written for 139 (31%). Appropriately, DNR decisions were correlated with severity of neurologic insult and poor prognosis. The authors suggest disease-specific criteria for making DNR decisions in acute stroke. An incidental finding is that 53% of patients continued to receive normal nutrition and 60% still received medical or surgical treatment [1]. Why? The answer to this question is beyond the scope of their study but is worth exploring. A quick review of the study data yields some interesting observations. Although mortality was by far the greatest in patients with severe strokes (65% versus 7% in those with moderate and 2% in those with mild strokes) and the DNR rate was also greatest in this group (77% versus 8% in the moderate group and 2% in the mild group), the rate of survival to discharge was also greatest among DNR patients in the most severe group. Thus, of the 123 patients with severe strokes who had DNR orders, 18 did not progress to cardiopulmonary arrest and left the hospital alive without the DNR order ever being triggered. Only two DNR patients with moderate and no DNR patients with mild strokes did not arrest and …

Resuscitation: Patient and staff attitudes in the context of cancer

One hundred oncology and hematology cancer patients from a major teaching hospital and their treating doctors were studied regarding their attitudes toward cardiopulmonary resuscitation (CPR). A descriptive approach was used, incorporating semistructured interviews of patients and medical staff and established questiomaire measures, examining knowledge of and attitudes toward disease and treatment, and projected attitude toward CPR and current psychological functioning. One-third of the patient sample anticipated a time when they would not consent to cardiopulmonary resuscitation. This was significantly associated with good disease prognosis. Patients with a psychiatric past history were also overrepresented. It appears that patient attitude to treatment withdrawal and refusal of CPR is related to disease progression and likely to change over time. This supports a dynamic and evolving model of advance directives rather than any fixed decree. Medical staff reported that they planned to provide half the sample with intensive medical treatment (including Intensive Care support in the event of their cardiac arrest), and 32% were designated for ward-based resuscitation only. Eighteen percent would not be resuscitated. These patients were older, had more treatment side effects, and a poorer quality of life. Those patients with either a psychiatric past history or higher ratings of depressive affect were also overincluded in the doctors' “Do-Not-Resuscitate” (DNR) group. These results suggest that there are other qualitative factors (e.g., current psychological functioning and past psychiatric history) that contribute to DNR decisions beyond the usual disease-based criteria seen in formal DNR protocols.