Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them

Cornell University, Итак, New York, United States
Journal of General Internal Medicine (Impact Factor: 3.42). 02/2011; 26(7):791-7. DOI: 10.1007/s11606-011-1632-x
Source: PubMed


Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.

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Available from: Michael D Fetters
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    • "She did not elicit patient goals of care in a way that took into account the context of the present admission or the risks and benefits of CPR, the way code statuses should be discussed (Downar and Hawryluck, 2010). She also did not educate the patient on her disease course, prognosis, benefits or drawbacks of CPR, nor did she provide a recommendation for or against resuscitation, as the literature recommends (Yuen et al., 2011). "
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    ABSTRACT: This article explores how structural factors associated with the profession and organization of medicine can constrain internal medicine residents, leading them to sometimes limit or terminate treatment in end-of-life care in ways that do not always embrace patient autonomy. Specifically, it examines the opportunities and motivations that explain why residents sometimes arrogate decision-making for themselves about life-sustaining treatment. Using ethnographic data drawn from over two years at an American community hospital, I contend that unlike previous studies which aggregate junior and senior physicians' perspectives, medical trainees face unique constraints that can lead them to intentionally or unintentionally overlook patient preferences. This is especially salient in cases where they misunderstand their patients' wishes, disagree about what is in their best interest, and/or lack the standing to pursue alternative ethical approaches to resolving these tensions. The study concludes with recommendations that take into account the structural underpinnings of arrogance in decision-making about life-sustaining treatment. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Mar 2015 · Social Science [?] Medicine
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    • "In addition, for both DNR-P and DNR-S forms, the date of signing was usually near the date of death, and the patient condition was typically serious. DNR discussion is insufficient and comes too late for patients, meaning that patient autonomy in decision making is not assured [2, 21]. For clinical care in Taiwan, families are more often a patient’s delegate, making the decisions for the patient. "
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    ABSTRACT: Purpose Discussing end-of-life care with patients is often considered taboo, and signing a do-not-resuscitate (DNR) order is difficult for most patients, especially in Chinese culture. This study investigated distributions and details related to the signing of DNR orders, as well as the completeness of various DNR order forms. Methods Retrospective chart reviews were performed. We screened all charts from a teaching hospital in Taiwan for patients who died of cancer during the period from January 2010 to December 2011. A total of 829 patient records were included in the analysis. The details of the DNR order forms were recorded. Results The DNR order signing rate was 99.8 %. The percentage of DNR orders signed by patients themselves (DNR-P) was 22.6 %, while the percentage of orders signed by surrogates (DNR-S) was 77.2 %. The percentage of signed DNR forms that were completely filled out was 78.4 %. The percentage of DNR-S forms that were completed was 81.7 %, while the percentage of DNR-P forms that were completely filled out was only 67.6 %. Conclusion Almost all the cancer patients had a signed DNR order, but for the majority of them, the order was signed by a surrogate. Negative attitudes of discussing death from medical professionals and/or the family members of patients may account for the higher number of signed DNR-S orders than DNR-P orders. Moreover, early obtainment of signed DNR orders should be sought, as getting the orders earlier could promote the quality of end-of-life care, especially in non-oncology wards.
    Preview · Article · May 2013 · Supportive Care in Cancer
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    • "심폐소생술 금지가 논의, 적용되었으며, 즉 심폐소생술 금지(do-notresuscitation , DNR)란, 갑작스러운 사고나 회복이 불가능할 정도로 심각한 말기 질환으로 인해 급성 호흡정지, 또는 심정지 시, 환자의 존엄한 죽음을 위하여 환자나 보호자의 동의하에 심폐소생술을 실시하지 않는 것을 말한다(Koh et al., 2011: Sinuff, Giacomini, Shaw, Swinton, & Cook, 2009; Yuen, Reid, & Fetters, 2011). "
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    ABSTRACT: Purpose: The purpose of the study was to explore the meaning of conflicts in nurses caring DNR (do-not-resuscitate) patients. Methods: The participants were 7 nurses caring DNR patients. Data were gathered using in-depth interviews. The interviews were recorded and transcribed verbatim. Colaizzi method was used to analyze the data. Results: The significant results can be categorized into 7 concept descriptions and 5 theme clusters by analyzing the interviews. The major theme clusters for the experiences of nurses were 'Pity about exceptional nursing actions', 'Pity about the unilateral decision making', 'Pity about halfhearted family love', 'Pity about unprepared circumstance for deathbed', and 'Pity about the absent guideline for DNR'. Conclusion: The finding of this study will help nurses resolve conflicts in caring DNR patients and provide a scientific basis for developing nursing intervention strategies for DNR patients.
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