Clinician Perspectives Regarding the Do-Not-Resuscitate Order

Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.
JAMA pediatrics 08/2013; 167(10). DOI: 10.1001/jamapediatrics.2013.2204
Source: PubMed


IMPORTANCE While data exist regarding the frequency and timing of the do-not-resuscitate (DNR) order in children, little is known about clinician attitudes and behaviors regarding this order. OBJECTIVE To identify clinician attitudes regarding the meaning, implication, and timing of the DNR order for pediatric patients. DESIGN Physicians and nurses from practice settings where advance care planning typically takes place were surveyed regarding their attitudes and behaviors about DNR orders. RESULTS In total, 107 physicians and 159 nurses responded to the survey (N = 266). There was substantial variability in the interpretation of the DNR order. Most clinicians (66.9%) believe that a DNR order indicates limitation of resuscitative measures only on cardiopulmonary arrest. In reality, however, more than 85% believe that care changes beyond response to cardiopulmonary arrest, varying from increased attention to comfort to less clinician attentiveness. In addition, most clinicians reported that resuscitation status discussions take place later in the illness course than is ideal. CONCLUSIONS AND RELEVANCE Clinicians use the DNR order not only as a guide for therapeutic decisions during a cardiopulmonary arrest but also as a surrogate for broader treatment directives. Most clinicians believe that DNR discussions should take place earlier than they actually do. Interventions aimed at improving clinician knowledge and skills in advance care discussions as well as the development of orders that address overall goals of care may improve care for children with serious illness.

1 Follower
6 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Goals of care discussions, including those focused on code status, are meant to foster autonomous decision making. Unfortunately, these discussions often conflate decisions regarding the use of cardiopulmonary resuscitation for cardiac arrest and mechanical ventilation for prearrest respiratory failure. They also exclude discussions of outcomes, particularly those associated with prearrest respiratory failure. In doing so, they may fail in their intention of extending patient autonomy. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine
    Journal of Hospital Medicine 10/2014; 9(10). DOI:10.1002/jhm.2234 · 2.30 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Pediatric advance care planning differs from the adult setting in several aspects, including patients' diagnoses, minor age, and questionable capacity to consent. So far, research has largely neglected the professionals' perspective. Aim: We aimed to investigate the attitudes and needs of health care professionals with regard to pediatric advance care planning. Design: This is a qualitative interview study with experts in pediatric end-of-life care. A qualitative content analysis was performed. Setting/participants: We conducted 17 semi-structured interviews with health care professionals caring for severely ill children/adolescents, from different professions, care settings, and institutions. Results: Perceived problems with pediatric advance care planning relate to professionals' discomfort and uncertainty regarding end-of-life decisions and advance directives. Conflicts may arise between physicians and non-medical care providers because both avoid taking responsibility for treatment limitations according to a minor's advance directive. Nevertheless, pediatric advance care planning is perceived as helpful by providing an action plan for everyone and ensuring that patient/parent wishes are respected. Important requirements for pediatric advance care planning were identified as follows: repeated discussions and shared decision-making with the family, a qualified facilitator who ensures continuity throughout the whole process, multi-professional conferences, as well as professional education on advance care planning. Conclusion: Despite a perceived need for pediatric advance care planning, several barriers to its implementation were identified. The results remain to be verified in a larger cohort of health care professionals. Future research should focus on developing and testing strategies for overcoming the existing barriers.
    Palliative Medicine 11/2014; 29(3). DOI:10.1177/0269216314552091 · 2.86 Impact Factor
  • Source

    The Journal of pediatrics 03/2015; 166(6). DOI:10.1016/j.jpeds.2015.02.019 · 3.79 Impact Factor