Do-not-resuscitate Research Articles

Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment.

Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment.

#4621 TREATMENT PREFERENCES TO SERIOUS ILLNESS IN PATIENTS RECEIVING PERITONEAL DIALYSIS

Abstract Background and Aims People with end-stage kidney disease receiving maintenance dialysis are more likely to receive intensive pattern of end-of-life care than those with other severe illness. It's important to understand the preferences to cardiopulmonary resuscitation (CPR) and other end-of-life care. However, no prior studies have investigated patients receiving peritoneal dialysis. This study aimed to explore the preference to CPR and patterns of end-of-life care in patient receiving peritoneal dialysis (PD), which had not been specifically investigated in the literature. Method This cross-sectional study of patients receiving PD was conducted in the National Taiwan University Hospital between Dec. 2021, and Mar. 2022. Patients were enrolled if they were 20 years or older, sufficiently fluent to complete surveys and cognitively able to provide written informed consent and had received maintenance peritoneal dialysis for at least 3 months. Enrollee were asked to the Chinese version of Physician Orders for Life-Sustaining Treatment questionnaire. Results Among 400 eligible patients, 364 (91%) responded to the questionnaire. The average age was 55.5 years; 50.3% were men. Among the 364 responders, 73.6% selected do not attempt resuscitation (DNR) and 26.4% preferred CPR. Multivariate logistic analysis revealed that age (OR = 0.96, 95% CI 0.94-0.98), male (OR = 2.44, 95% CI 1.45-4.1) and residual kidney Kt/V (OR = 2.45 95% CI 1.24-4.82) were associated with CPR. If they are facing on serious illness, 47.5% of participants prefer to “Focus on comfort”, 28.6% choose “try treatments, but do not suffer” and 23.9% request “live as long as possible”. Furthermore, 51.4% of participants selected “No artificial nutrient support” in the end of life and 87.1% select “comfort care” as their first priority. Paradoxically, only 13.5% of the patients who preferred CPR took “staying alive” as their first priority, while 71.9% focused on “comfort care”. Conclusion Around 75% of PD patients selected DNR when cardiopulmonary arrest. Age, gender, residual Kt/V were important factors associated with CPR preference. Most patients preferred supportive pattern of end-of-life care. Integrating patients' treatment preference to serious illness and values and goals of end-of-life care in shared decision making is important for patients receiving dialysis.

End-of-life care and hospital-acquired bloodstream infection

Background: All critically ill patients are at risk for hospital-acquired bloodstream infection (HABSI). At any time, however, there is heterogeneity among patients in the ICU; some patients have the added complexity of end-of-life discussions. We sought to better understand the patients in our medical intensive care unit (MICU) with HABSIs that do and do not meet the NHSN definition for a central-line–associated bloodstream infection (CLABSI) event by evaluating for the presence of a do-not-resuscitate (DNR) order. Methods: The study was conducted at our 66-bed MICU at the Cleveland Clinic Main Campus between January 2021 and September 2022. Surveillance for HABSI to include determination of CLABSI is performed prospectively according to the NSHN definition. The electronic health record was queried for each patient with a HABSI for the presence of a DNR order. DNR orders were categorized as follows: prevalent (DNR orders present at the time of admission to the MICU), incident (orders entered after admission to the MICU), or no DNR (for patients without an order at any time during their MICU stay). For incident orders, time from order to HABSI was recorded. Time to event was calculated as days between ICU admission to HABSI. Results: During the observation period there were 36,477 MICU patient days and 4,815 admissions. There were 112 HABSIs, of which 48 (43%) were CLABSIs. Overall, 65 patients were categorized as incident DNR, 7 were categorized as prevalent DNR, and 40 were categorized as no DNR. For patients with an incident DNR order, 50 HABSIs occurred on the date of or before the order and 15 occurred after the order. In patients in whom HABSI occurred after the incident DNR order, the median number of days between DNR order and HABSI was 11 days (range, 1–69). Discussion: In our MICU, >50% of HABSIs and 60% of CLABSIs occurred in patients with a DNR order incident to their MICU stay. Interventions to prevent hospital-acquired bloodstream infection and the analysis of the events are inextricably linked to issues of end-of-life care for critically ill patients. Further exploration of patient characteristics easily obtainable from the EHR, such as DNR orders, is necessary to inform best practices for prevention and risk adjustment of bloodstream infection rates.Disclosures: None

Impact of homelessness on outcomes among pancreatic cancer hospitalization: Insight from the 2016-2020 National Inpatient Sample.

e16264 Background: Homelessness is a major socio-economic issue in the United States, affecting an estimated 171 per 100,000 persons in certain states. While pancreatic cancer (PC) tends to have a poor prognosis, the disease requires an early diagnosis, proper care, and follow-ups. As there is a paucity of data highlighting differences in patient characteristics and outcomes of homeless patients with PC, a retrospective study was conducted via a national database. Methods: We used data from the 2016-2020 National Inpatient Sample (NIS), the most extensive hospital database, to identify patients with a diagnosis of pancreatic cancer. Patients with a status of “homeless” were located via the ICD-10 code “Z590”, per suggestions from HCUP and past studies. Several differences in patient characteristics were explored between homeless cases of PC and non-homeless cases via Pearson’s Chi-Square tests. Finally, the adjusted odds ratio (aOR) and 95% Confidence intervals (CI) of various outcomes such as mortality, pulmonary embolism, septicemia, and hepatic failure were calculated via multivariable logistic regression models. Results: Our study identified 544855 pancreatic cancer cases, including 1380 patients classified as homeless (0.3%). 81.5% of homeless patients were males (vs. 52.1%), and 24.6% were admitted on weekends (vs. 20.6%). Moreover, Medicaid was the prime insurer among homeless patients (47.6% vs. 8.6%) with a higher mean hospital charge ($86796 vs. $70610). Racial differences were also observed as 51.9% of homeless cases were Whites (vs. 71.2%), while 31.6% (vs. 13.8%) were Blacks, and 11.3% (vs. 8.2%) were Hispanics. A higher proportion of homeless cases had palliative care utilization (27.9% vs. 19.1%), a Do-Not-Resuscitate (DNR) order (25.7% vs. 23.1%), and required pancreatic and proximal biliary dilation/stenting (4.0% vs. 2.2%). Homeless patients admitted with pancreatic cancer also expressed higher odds of in-hospital mortality (8.7% vs. 7.4%, aOR 1.625, 95% CI 1.280-2.064, p<0.01). No statistical significance was found for events of pulmonary embolism (aOR 1.231, p=0.160), septicemia (aOR 1.044, p=0.674), and hepatic failure (aOR 0.892, p=0.549). Conclusions: Homeless patients with PC were linked with higher in-patient mortality. Various racial and socio-economic differences were also observed. Several efforts to ameliorate access to care among homeless patients and an early diagnosis may help improve the outcomes.

The IMPACT of an interdisciplinary goals-of-care program on readmission rates at a comprehensive care center.

6565 Background: Unplanned readmissions are associated with substantial distress for patients and their families. We hypothesized that goals-of-care (GOC) discussions, by improving goal-concordant care, may reduce unplanned readmissions. However, only a handful of studies have specifically examined this question. We assessed the implementation of a system-wide multicomponent interdisciplinary GOC (myGOC) program on the 30-day unplanned readmission rate and other hospital outcomes for medical patients at our comprehensive cancer center. Methods: In this retrospective cohort study, we compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period from May 1, 2019 to December 31, 2019 and the post-implementation period from May 1, 2020 to December 31, 2020. The primary outcome was the 30-day unplanned readmission rate as defined by Vizient. Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders and supportive care consults. A multi-variate analysis model was used to examine the association between 30-day unplanned readmission rates and the implementation of the myGOC program adjusting for age, sex, race, index hospitalization type, and Sequential Organ Failure Assessment (SOFA) score. Results: This study included 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The 30-day unplanned readmission rates decreased from 13.7% before to 12.0% after implementation of the myGOC program. After adjusting for covariates, the myGOC implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p=0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were hematologic malignancies (vs. solid: 0.71 [0.64, 0.79]), White race (vs. Hispanic: 0.86 [0.75, 0.98]), an inpatient DNR order (0.30 [0.25, 0.37], an ICU admission (0.58 [0.48, 0.71], and an emergent admission (vs. elective: 0.86 [0.76, 0.99]). We also observed a significant decrease in 7-day unplanned readmission rates (0.75 [0.64, 0.89], p=0.0009), an increase in inpatient DNR orders (1.48 [1.35, 1.63], p<0.0001) and an increase in supportive care consults (1.22 [1.13, 1.31], p<0.0001) post-implementation. Conclusions: Implementation of a system-wide multicomponent GOC intervention was associated with a significant reduction in 30-day unplanned readmission rates after accounting for other key clinical factors.

Early Versus Late Outpatient Pediatric Palliative Care Consultation and Its Association With End-of-Life Outcomes in Children with Cancer.

Background: There is no consensus on what constitutes "early" pediatric palliative care (PPC) referral within pediatric oncology. Few studies report outcomes based on PPC timing. Objectives: Investigate associations between early (<12 weeks) or late (≥12 weeks from diagnosis) outpatient PPC consultation with demographics, advance care planning (ACP), and end-of-life (EOL) outcomes. Design: Retrospective chart and database review of demographic, disease, visit data, and PPC/EOL outcomes. Setting/Subjects: Deceased pediatric patients with cancer 0-27 years of age seen at an embedded consultative PPC clinic. Measurements: Patient demographics, disease characteristics, PPC/EOL outcomes: timing/receipt of ACP, hospice enrollment, do-not-resuscitate (DNR) documentation, hospital days in last 90 days of life, concordance between actual and preferred location of death, receipt of cardiopulmonary resuscitation (CPR) at EOL, and death in the intensive care unit. Results: Thirty-two patients received early and 118 received late PPC. Early outpatient PPC was associated with cancer type (p < 0.01). Early PPC (p = 0.04) and ACP documentation (p = 0.04) were associated with documentation of preferred location of death. Early PPC was associated with a preference for home death (p = 0.02). Timing of outpatient PPC was not associated with ACP documentation or other EOL outcomes. In the entire cohort, 73% of PPC patients received hospice, 74% had a DNR order, 87% did not receive CPR at EOL, and 90% died in their preferred location. Conclusions: When using a cutoff of 12 weeks from diagnosis, outpatient PPC timing was only associated with location of death metrics, likely due to high-quality PPC and EOL care among all patients.

Knowledge gaps, attitudes, and practices regarding end-of-life medical care among physicians in an academic medical center

&lt;b&gt;Introduction:&lt;/b&gt; End-of-life medical care (ELMC) plans and do-not-resuscitate (DNR) decision-making are usually affected by multiple factors compared to other medical care decisions.&lt;b&gt; &lt;/b&gt;ELMC and DNR policy implementation are still diversified and heterogeneous, especially in Saudi Arabia, because policymakers have adopted no guidelines. Thus, this study investigated physicians’ knowledge, attitude, and practice regarding ELMC and DNR.&lt;br /&gt; &lt;b&gt;Methods:&lt;/b&gt; A cross-sectional study design was adopted. Three hundred physicians working at King Fahad Hospital of the University, Khobar, Saudi Arabia, were randomly selected and administered an anonymous self-administered questionnaire using the Likert scale. Data analysis was carried out using SPSS 23.0.&lt;br /&gt; &lt;b&gt;Results: &lt;/b&gt;Of 300 distributed questionnaires, 264 (88%) were completed and analysed. Knowledge gaps and negative attitudes were observed, a quarter of the participants were opposed to issuing a DNR order, and 29.0% considered DNR as equal to euthanasia as they practice. The participants’ patient age and religious factors were the most critical factors in the ELMC plan and DNR decision. The physician’s level of acceptance regarding a set of ELMC interventions and DNR decisions showed heterogenicity and uncertainty among participants.&lt;br /&gt; &lt;b&gt;Conclusions:&lt;/b&gt; The ELMC plan and DNR decision-making should be appropriately addressed in the medical residents’ training programs to bridge the knowledge gap and the physicians’ negative attitudes during their practice. Additionally, there is a need to update and unify the DNR policies at the national level, considering the patient’s right to be informed and involved actively during the decision process making. Finally, more prospective research is needed for the global standardization of ELMC.

Predicting the probability of good neurological outcome after in-hospital cardiac arrest based on prearrest factors: validation of the good outcome following attempted resuscitation 2 (GO-FAR 2) score.

The Good Outcome Following Attempted Resuscitation (GO-FAR) 2 score is a prognostic tool developed to support decision-making for do-not-attempt-resuscitation (DNAR) orders by predicting neurological outcomes after in-hospital cardiac arrest (IHCA) based on prearrest variables. However, this scoring system requires further validation. We aimed to validate the GO-FAR 2 score for predicting good neurological outcome in Korean patients with IHCA. A single-centre registry of adult patients with IHCA from 2013 to 2017 was analysed. The primary outcome was discharge with good neurological outcome (Cerebral Performance Category score of 1 or 2). The patients were divided into four categories according to the GO-FAR 2 score: very poor (≥ 5), poor (2-4), average (-3 to 1), and above-average (< -3) likelihood of good neurological outcome. Of 1,011 patients (median age, 65years), 63.1% were men. The rate of good neurological outcome was 16.0%. The proportions of patients categorised as having very poor, poor, average, and above-average probability of good neurological outcome were 3.9%, 18.3%, 70.2%, and 7.6%, respectively. In each category, good neurological outcome was observed in 0%, 1.1%, 16.8%, and 53.2%, respectively. Among patients in below-average categories (very poor + poor, GO-FAR 2 score ≥ 2), only 0.9% had good outcome. GO-FAR 2 score ≥ 2 showed a sensitivity of 98.8% and a negative predictive value of 99.1% in predicting good neurological outcome. The GO-FAR 2 score can predict neurological outcome after IHCA. In particular, GO-FAR 2 score ≥ 2 may support decision-making for DNAR orders.

Enhancing Expert Panel Discussions in Pediatric Palliative Care: Innovative Scenario Development and Summarization With ChatGPT-4.

This study presents a novel approach to enhance expert panel discussions in a medical conference through the use of ChatGPT-4 (Generative Pre-trained Transformer version 4), a recently launched powerful artificial intelligence (AI) language model. We report on ChatGPT-4's ability to optimize and summarize the medical conference panel recommendations of thefirst Pan-Arab Pediatric Palliative Critical Care Hybrid Conference, held in Riyadh, Saudi Arabia.ChatGPT-4 was incorporated into the discussions in two sequential phases: first, scenarios were optimized by the AI model to stimulate in-depth conversations; second, the model identified, summarized, and contrasted key themes from the panel and audience discussions. The results suggest that ChatGPT-4 effectively facilitated complex do-not-resuscitate (DNR) conflict resolution by summarizing key themes such as effective communication, collaboration, patient and family-centered care, trust, and ethical considerations. The inclusion of ChatGPT-4 in pediatric palliative care panel discussions demonstrated potential benefits for enhancing critical thinking among medical professionals. Further research is warranted to validate and broaden these insights across various settings and cultures.

Changes over time in POLST use and content by race and ethnicity among California nursing home residents.

Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity. California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned. POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups. Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative.

Physician perspectives on the DNR order in Turkey: A survey of physicians in Internal Medicine.

Do not resuscitate (DNR) is a controversial ethico-legal issue and there is no legal regulation in Turkey. Evaluating the physicians' views on DNR is critical to the current problems and contributes to legal regulation. To examine the views of intensive care unit residents on DNR and the sociocultural and occupational factors affecting them. The research is a descriptive cross-sectional study. The sample of the study consists of 203 residents of internal medicine working in the intensive care unit in a university hospital. A questionnaire form was used as a data collection tool. 62.6% of the physicians know that there is no legal regulation regarding DNR in Turkey, and 14.3% think that DNR is performed. Female physicians approve of DNR at a higher rate than men (p<0.01). Physicians with more experience in the profession stated that not all patients should be performed cardiopulmonary resuscitation (p<0.01), and DNR should be a right (p<0.05). The vast majority of physicians stated that DNR should be legal (88.1%) and should be included in residency training (85.6%). It is necessary to establish legal regulations on DNR and implement residency training programs that will ensure the continuous professional development of physicians.

Association Between Opening a Palliative Care Unit and Hospital Care for Patients With Serious Illness.

Background: Palliative care units (PCUs) are devoted to intensive management of symptoms and other palliative care needs. We examined the association between opening a PCU and acute care processes at a single U.S. academic medical center. Methods: We retrospectively compared acute care processes for seriously ill patients admitted before and after the opening of a PCU at a single academic medical center. Outcomes included rates of change in code status to do-not-resuscitate (DNR) and comfort measures only (CMO) status, and time to DNR and CMO. We calculated unadjusted and adjusted rates and used logistic regression to assess interaction between care period and palliative care consultation. Results: There were 16,611 patients in the pre-PCU period and 18,305 patients in the post-PCU period. The post-PCU cohort was slightly older, with a higher Charlson index (p < 0.001 for both). Post-PCU, unadjusted rates of DNR and CMO increased from 16.4% to 18.3% (p < 0.001) and 9.3% to 11.5% (p < 0.001), respectively. Post-PCU, median time to DNR was unchanged (0 days), and time to CMO decreased from 6 to 5 days. The adjusted odds ratio was 1.08 (p = 0.01) for DNR and 1.19 (p < 0.001) for CMO. Significant interaction between care period and palliative care consultation for DNR (p = 0.04) and CMO (p = 0.01) suggests an important role for palliative care engagement. Conclusions: The opening of a PCU at a single center was associated with increased rates of DNR and CMO status for seriously ill patients.

Associations between Latino ethnicity and the use of emotional support and completion of advance directives.

Latino patients have been shown to engage in advance care planning (ACP) at much lower rates than non-Latino White patients. Coping strategies, such as the use of emotional support, may differentially relate to engagement in ACP among Latino and non-Latino patients. The present study sought to examine the moderating effect of ethnicity on the relationship between the use of emotional support as a coping strategy and completion of advance directives. The present study employed a weighted sample (Nw = 185) of Latino and non-Latino White patient participants in Coping with Cancer III, an National Institutes of Health-sponsored, multisite, longitudinal, observational cohort study of patients with advanced cancer and their informal caregivers and oncology providers designed to evaluate Latino/non-Latino disparities in ACP and end-of-life cancer care. Main and interaction effects of Latino ethnicity and use of emotional support on patient use of advance directives were estimated as odds ratios. Use of emotional support was associated with dramatically lower do-not-resuscitate (DNR) order completion to a greater extent among Latino as compared to non-Latino patients (interaction AOR = 0.33, p = 0.005). Interaction effects were not statistically significant for living will or health-care proxy form completion. Use of emotional support is associated with lower odds of completing DNRs among Latino than among non-Latino patients. Seeking and/or receiving emotional support may deter Latino patients from completing DNR orders. Research is needed to address both emotional needs and practicalities to ensure high quality end-of-life care among Latino patients with cancer.

Quality of End-of-Life Care during the COVID-19 Pandemic at a Comprehensive Cancer Center.

To evaluate how the COVID-19 pandemic impacted the quality of end-of-life care for patients with advanced cancer, we compared a random sample of 250 inpatient deaths from 1 April 2019, to 31 July 2019, with 250 consecutive inpatient deaths from 1 April 2020, to 31 July 2020, at a comprehensive cancer center. Sociodemographic and clinical characteristics, the timing of palliative care referral, timing of do-not-resuscitate (DNR) orders, location of death, and pre-admission out-of-hospital DNR documentation were included. During the COVID-19 pandemic, DNR orders occurred earlier (2.9 vs. 1.7 days before death, p = 0.028), and palliative care referrals also occurred earlier (3.5 vs. 2.5 days before death, p = 0.041). During the pandemic, 36% of inpatient deaths occurred in the Intensive Care Unit (ICU) and 36% in the Palliative Care Unit, compared to 48 and 29%, respectively, before the pandemic (p = 0.001). Earlier DNR orders, earlier palliative care referrals, and fewer ICU deaths suggest an improvement in the quality of end-of-life care in response to the COVID-19 pandemic. These encouraging findings may have future implications for maintaining quality end-of-life care post-pandemic.

Cost-Savings of Do Not Resuscitate Orders Among Elderly Patients With Heart Failure in the United States.

Do-not-resuscitate (DNR) orders should preclude the use of cardiopulmonary resuscitation and may be associated with patient outcomes for patients hospitalized with heart failure (HF). This study examined the association between DNR and costs, mortality, and length of stay. The study cohort was a national sample of 700 922 hospital admissions of patients aged >65 with a primary diagnosis of HF. Elderly HF patients who died with a DNR had cost-savings of $5640 ( P < 0.001). Patients with a DNR order were 8.9% points more likely to die before discharge than patients without ( P < 0.001), and patients who died with a DNR had a significantly shorter hospital stay by 1.51 days ( P < 0.001). DNR orders among elderly patients with HF are associated with cost-savings, as well as a higher mortality and shorter length of stay. In addition to primary benefits, advance care planning may aid in containing costs of care at end of life for HF.

Change in Code Status Orders of Hospitalized Adults With COVID-19 Throughout the Pandemic: A Retrospective Cohort Study.

Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.

Ethical issues of do not resuscitate in cancer patients: A narrative review from a nursing perspective

This narrative review aims to examine the ethical issues of do not resuscitate order (DNR) in cancer patients from a nursing perspective. Keywords were obtained based on Medical Subject Headings with titles related to the topic of the article. The data was obtained by searching English keywords (cardiopulmonary resuscitation, cancer, dilemma, oncology) in the title and abstract of the PubMed, Scopus, and Web of Science databases without time limits to access published foreign studies. Also, to access published Persian studies, Iranian websites, including Scientific Information Database, Magiran, and Iranmedex scientific databases, were searched with equivalent Persian keywords. Also, based on the determined keywords, a free search was also conducted in the Google Scholar search engine. The study on the implementation of DNR orders by healthcare providers has been of interest to medical staff, patients, and their families in the past. The issue of choosing between life and death to reduce pain and suffering and the lack of facilities to treat patients in the last stages of the disease is one of the main reasons for making a DNR order, especially in cancer patients who are going through the last stages of their lives. In various studies, various aspects of the treatment staff's and patients' attitudes were examined, but the most attention is paid to factors such as the doctor's moral competence, the patient's independence, the quality of life, and adopting the right time for this order. In these studies, it has been shown that the DNR order is widely used in patients with advanced cancers. Therefore, managers and policymakers in the health field should provide a platform for training the medical care team, especially nurses, in the field of various aspects of the ethical competence of DNR and interaction with these patients and their families.

Obstacles to patient inclusion in CPR/DNAR decisions and challenging conversations: A qualitative study with internal medicine physicians in Southern Switzerland.

Despite cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) decisions are increasingly considered an essential component of hospital practice and patient inclusion in these conversations an ethical imperative in most cases, there is evidence that such discussions between physicians and patients/surrogate decision-makers (the person or people providing direction in decision making if a person is unable to make decisions about personal health care, e.g., family members or friends) are often inadequate, excessively delayed, or absent. We conducted a study to qualitatively explore physician-reported CPR/DNAR decision-making approaches and CPR/DNAR conversations with patients hospitalized in the internal medicine wards of the four main hospitals in Ticino, Southern Switzerland. We conducted four focus groups with 19 resident and staff physicians employed in the internal medicine unit of the four public hospitals in Ticino. Questions aimed to elicit participants' specific experiences in deciding on and discussing CPR/DNAR with patients and their families, the stakeholders (ideally) involved in the discussion, and their responsibilities. We found that participants experienced two main tensions. On the one side, CPR/DNAR decisions were dominated by the belief that patient involvement is often pointless, even though participants favored a shared decision-making approach. On the other, despite aiming at a non-manipulative conversation, participants were aware that most CPR/DNAR conversations are characterized by a nudging communicative approach where the physician gently pushes patients towards his/her recommendation. Participants identified structural cause to the previous two tensions that go beyond the patient-physician relationship. CPR/DNAR decisions are examples of best interests assessments at the end of life. Such assessments represent value judgments that cannot be validly ascertained without patient input. CPR/DNAR conversations should be regarded as complex interventions that need to be thoroughly and regularly taught, in a manner similar to technical interventions.

Validity of ICD codes to identify do-not-resuscitate orders among older adults with heart failure: A single center study.

Observational research on the advance care planning (ACP) process is limited by a lack of easily accessible ACP variables in many large datasets. The objective of this study was to determine whether International Classification of Disease (ICD) codes for do-not-resuscitate (DNR) orders are valid proxies for the presence of a DNR recorded in the electronic medical record (EMR). We studied 5,016 patients over the age of 65 who were admitted to a large, mid-Atlantic medical center with a primary diagnosis of heart failure. DNR orders were identified in billing records from ICD-9 and ICD-10 codes. DNR orders were also identified in the EMR by a manual search of physician notes. Sensitivity, specificity, positive predictive value and negative predictive value were calculated as well as measures of agreement and disagreement. In addition, estimates of associations with mortality and costs were calculated using the DNR documented in EMR and the DNR proxy identified in ICD codes. Relative to the gold standard of the EMR, DNR orders identified in ICD codes had an estimated sensitivity of 84.6%, specificity of 96.6%, positive predictive value of 90.5%, and negative predictive value of 94.3%. The estimated kappa statistic was 0.83, although McNemar's test suggested there was some systematic disagreement between the DNR from ICD codes and the EMR. ICD codes appear to provide a reasonable proxy for DNR orders among hospitalized older adults with heart failure. Further research is necessary to determine if billing codes can identify DNR orders in other populations.

Assessment of surgery residents' knowledge of medical ethics and law. Implications for training and education.

Medical ethics and law are essential topics that should be included in medical residency programs. However, surgery training programs in Iran lack a specific course in medical ethics and law, which can lead to patient dissatisfaction with surgical outcomes. This study aimed to assess surgery residents' knowledge of medical ethics and law and suggest improvements for future residency programs. This descriptive cross-sectional study involved 112 surgery residents from six teaching hospitals. A valid and reliable questionnaire comprising 15 items on medical ethics and 12 items on medical law was used to assess participants' knowledge. Most participants were female (31-40 years old), and their mean knowledge score for medical ethics was 3.26±0.53 out of 5, with the lowest score in "futile treatment and DNR orders." The mean knowledge score for medical law was 3.69±0.69, with the lowest score in "surrogate decision-maker." Age did not affect residents' knowledge, but gender did, with female residents demonstrating significantly better knowledge of medical ethics (3.344/5 vs. 3.112/5) and law (3.789/5 vs. 3.519/5). Surgery residents had a relatively favorable knowledge of medical ethics and law, but they require further training in some areas to improve their knowledge. Training should include journal clubs, role-play programs, standardized patient programs, and debates to achieve better results, as purely didactic lectures appear inadequate.