Experiences and views of specialist registrars in geriatric medicine on 'do not attempt resuscitation' decisions: A sea of uncertainty?

University of Cambridge, Cambridge, England, United Kingdom
QJM: monthly journal of the Association of Physicians (Impact Factor: 2.5). 11/2006; 99(10):691-700. DOI: 10.1093/qjmed/hcl096
Source: PubMed
ABSTRACT
Recent cultural changes place doctors under increasing pressure to work with their patients to reach decisions about end-of-life care.
To survey the experience, practice and opinions of specialist registrars (SPRs) in geriatric medicine regarding 'do not attempt resuscitation' (DNAR) decisions.
Postal questionnaire survey.
A questionnaire was mailed to all members registered as trainees (n = 408) with the British Geriatrics Society in November 2003; a reminder was sent nine weeks later. Responses were analysed using both quantitative and qualitative (thematic) approaches.
Response rate was 62% (251/408), of whom 235 were still SpRs. Respondents played a major role in DNAR decision-making in their day-to-day clinical practice. Over a third of respondents did not feel that locally available guidelines were helpful. More than half sometimes disagreed with their consultants' decision, and a fifth were concerned about the possibility of complaints regarding the decisions they made. The majority felt uncomfortable discussing the issue with the patient, and were more likely to discuss the issue with relatives than with patients.
Further support and training may improve confidence and positive experiences in relation to DNAR decision-making among training-grade doctors in the UK.

Full-text

Available from: Phyo K Myint
Experiences and views of specialist registrars in geriatric
medicine on ‘do not attempt resuscitation’ decisions:
a sea of uncertainty?
P.K. MYINT
1,2,3
, S. MILES
2
, D.A. HALLIDAY
4
and L.K. BOWKER
1,2
From the
1
Department of Medicine for the Elderly, Norfolk and Norwich University Hospital,
Norwich,
2
School of Medicine, Health Policy and Practice, University of East Anglia, Norwich,
3
Clinical Gerontology Unit & Lewin Stroke Unit, Addenbrooke’s Hospital, University of Cambridge,
Cambridge, and
4
East of England Research and Development Support Unit—Norfolk and Suffolk,
University of East Anglia, Norwich, UK
Received 3 March 2006 and in revised form 19 June 2006
Summary
Background: Recent cultural changes place
doctors under increasing pressure to work with
their patients to reach decisions about end-of-life
care.
Aim: To survey the experience, practice and
opinions of specialist registrars (SPRs) in geriatric
medicine regarding ‘do not attempt resuscitation’
(DNAR) decisions.
Design: Postal questionnaire survey.
Methods: A questionnaire was mailed to all
members registered as trainees (n ¼ 408) with the
British Geriatrics Society in November 2003; a
reminder was sent nine weeks later. Responses were
analysed using both quantitative and qualitative
(thematic) approaches.
Results: Response rate was 62% (251/408), of whom
235 were still SpRs. Respondents played a major
role in DNAR decision-making in their day-to-day
clinical practice. Over a third of respondents did not
feel that locally available guidelines were helpful.
More than half sometimes disagreed with their con-
sultants’ decision, and a fifth were concerned about
the possibility of complaints regarding the decisions
they made. The majority felt uncomfortable discuss-
ing the issue with the patient, and were more likely to
discuss the issue with relatives than with patients.
Discussion: Further support and training may
improve confidence and positive experiences
in relation to DNAR decision-making among
training-grade doctors in the UK.
Introduction
Despite growing awareness of ‘do not attempt
resuscitation’ (DNAR) orders and emergence of
guidelines, around 20% of patients who die in UK
hospitals will have one or more attempts at
cardiopulmonary resuscitation (CPR) during their
terminal admission.
1
Recent cultural changes,
including increasing patient and family involvement
in health-care decisions, a political drive to offer
choices to patients, and growing anxiety about
litigation, mean that doctors are under increasing
pressure to work together with their patients to reach
decisions about end-of-life care.
Various professional bodies have produced CPR/
DNAR guidelines since Doyal and Wilsher’s pub-
lication in 1993,
2
where the requirement of formal
guidance on CPR was first proposed. In 2000, the
Chief Medical Officer, who oversees the medical
practitioners in England in Wales, stated that all
NHS trusts should generate individual guidelines
that ‘respect patients’ rights, are understood by all
Address correspondence to Dr Phyo Kyaw Myint, c/o Clinical Gerontology Unit, Level 2, F & G Block, Box 251,
Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 2QQ. email: pkyawmyint@aol.com
!
The Author 2006. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
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doi:10.1093/qjmed/hcl096
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relevant staff, and accessible to those who need
them, and that such policies are subject to appro-
priate audit and monitoring arrangements’.
3
Earlier
guidelines from the Royal College of Physicians,
4
the British Geriatrics Society
5
and the British
Medical Association
6
preceded the Human Rights
Act, which was implemented in the UK in late 2000.
Several of the articles of the Act aim, directly
or indirectly, to make doctors more aware of
their obligations to involve their patients in their
DNAR/CPR decision-making.
7
This has led to further
guidelines being produced by the British Medical
Association, in conjunction with the Resuscitation
Council (UK) and the Royal College of Nursing
(BMA/RCUK/RCN),
8
and recent guidance from
the General Medical Council (GMC).
9
However,
the legality of the GMC guidelines has been
challenged recently.
10
This case highlights the
possibility of future challenges over DNAR
decisions made by front-line clinicians, even when
professional guidelines are followed.
O’Keefe described his own experience with
guidelines in relation to the practicality of imple-
menting them,
11
and concluded that it is difficult
to involve acutely ill patients in DNAR decision-
making. Most studies to date, however, have mainly
focussed on adherence to guidelines (e.g. following
legible recording of orders or following steps) rather
than the personal experience and preferred clinical
practice of decision-makers.
In everyday clinical practice of DNAR decision-
making, it is not uncommon to encounter unreason-
able demands from patients themselves or their
relatives, which can produce conflict, and take time
and skill to resolve. Therefore, it is essential that
doctors in higher specialist training receive appro-
priate training and support in this area. In the UK,
geriatricians are the largest group of physicians
who provide not only acute and community services
to older people but also acute medical service to
younger adults. Higher medical training at specialist
registrar (SpR) level in geriatric medicine in the
UK involves five years of clinical training after a
post-graduate qualification, MRCP (UK) diploma or
equivalent, and requires at least two years experi-
ence in acute hospital medicine at senior house
officer level (medical officer equivalent). Following
this, a certificate of completion of training in general
internal medicine and geriatric medicine is
awarded, enabling doctors to take up a consultant
post in the NHS. Consultants in the UK are
specialists who practice independently and also
responsible for training of future consultants.
In this study, we examine current clinical
experience and the routine approach to DNAR
decision-making of specialist registrars (SpRs) in
geriatric medicine. The rationale for focussing on
higher trainees in geriatric medicine is mainly that in
the UK, geriatricians are not only the largest group of
physicians, but also most likely to be involved with
the DNAR decision-making process. Therefore, it is
important to identify the experiences and views
of SpRs, as future leaders of geriatric medicine, to
enable provision of adequate support and training.
Methods
In November 2003, a questionnaire designed to
investigate DNAR decision-making was mailed to
trainee members of the British Geriatrics Society
(BGS), inviting their voluntary responses. The mail-
ing list was obtained from the BGS registration
office. The questionnaire incorporated both quanti-
tative and qualitative items to explore respondents’
routine clinical practice and views on DNAR
decision-making. Free entry into an author-funded
prize draw was offered as an inducement.
A reminder was sent to non-responders 9 weeks
after the first mailing.
The questionnaire contained four domains
(Appendix, questions 1–4) examining the respon-
dents’ clinical experience, current decision-making
practice, preferences concerning involvement
with such decision-making processes, and personal
experiences. These four domains were structured as
follows: Question 1, clinical experience (years of
practice in the UK since graduation, involvement
in cardiac arrest situation, experience of cardiac
arrest situation), self-reported frequency of DNAR
decision-making outside team structure, awareness
and experience of local guidelines; Question 2,
current decision-making practice involving inter-
action with patients or relatives (responses to given
scenarios); Question 3, preference concerning
involvement with such decision-making processes;
Question 4, personal opinion, memorable experi-
ences and predictions as to the future of the DNAR
decision-making process (free text).
Quantitative data were analysed using SPSS
for Windows version 12.0.1 (SPSS Inc.) using a
significance level of p < 0.05. Free text data were
analysed qualitatively using a thematic coding
schema. Themes were derived from the textual
data. Frequency and percentages were given for
each response. Two coders (SM and DAH) each
analysed half of the reported data. Inter-coder
agreement was checked by each coder analysing
10% of the other coders’ data. Disagreements
were discussed until a consensus was reached.
This process resulted in some codes being merged.
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Themes from the data were discussed with PKM and
LKB to check for clinical and contextual accuracy.
Results
After two mailings, the overall response rate was
62% (251/408). Of these, 16 were no longer SpR
grade. Therefore, analyses were based on the
remaining 235 responses from SpRs (94% of 251).
Not every respondent answered all the questions.
Respondents had practiced medicine in the
UK for a median 8 years (range 1–20) and
attended cardiac arrest calls for a median 6 years
(range 1–14).
The majority were involved with DNAR decisions
‘sometimes’ or ‘commonly’ in patients who were
not under their care (195, 83%), and they did make
DNAR decisions in younger adults (18–55 years)
(186, 80%). Whilst almost all SpRs participating in
this study (227, 97%) were aware of the presence or
absence of local Trust guidelines in DNAR decision-
making, only two-thirds (123, 63%) of the 195
respondents whose Trusts had such a policy thought
it was helpful in their day-to-day practice.
In relation to this, when asked what document/
guideline they would recommend as guidance for
DNAR decisions for their colleagues, 28% (66)
provided no response, indicating that over a quarter
of the respondents had no document/guideline that
they would recommend. Of those recommending
a guideline, about a fifth recommended their own
trust/local guidelines (48, 21%), or BMA guidelines
(45, 19%). Joint BMA/RCUK/RCN guidelines were
recommended by 29 (12%) respondents and GMC
guidelines by 27 (11%). A few respondents stated
that they would recommend discussion with the
patient or senior clinician, or using common sense
instead of recommending a particular guideline
(Box 1, Quotes 4(b): 1102, 1244). There was a
suggestion that there were various inadequacies
with current guidelines (Box 1, Quotes 4(b), 1014,
1113). These inadequacies may have led to anxiety
such as fear of complaint or litigation in relation to
DNAR decisions (Box 1, Quotes 4(b), 1109).
Table 1 summarizes the responses from questions
where respondents were asked about their current
clinical experience with DNAR decisions. Relatively
few of the respondents seek the patient’s opinion
on DNAR decisions. In contrast, the majority
discuss the DNAR decision with a relative and
seek relatives’ opinion as a ‘proxy’ to the patient’s
opinion in DNAR decision-making. Some 44%
(n ¼ 101) base their DNAR decisions primarily on
expected quality of life after resuscitation over half
the time, and 71% (n ¼ 164) base decisions on the
likelihood of successful resuscitation over half of
the time. While 43% (n ¼ 100) would never make
a partial DNAR decision, an almost equal number
of SpRs would make such a decision at times.
When respondents were asked to detail the single
most important influencing factor in making DNAR
decisions, almost a third (72, 31%) said that
likelihood of success was a key influencing factor
(Box 1, Quotes 4(d): 1002, 1103), futility was
mentioned as an influencing factor for 18 (8%)
and the patient’s prognosis for 17 (7%). For these
respondents, the likelihood of a poor outcome,
futility and poor prognosis would lead them to
a DNAR decision. The patient’s medical condition
was a key influencing factor for 80 of the
respondents (34%) (Box 1, Quotes 4(d), 1141).
Of these, 14 stated that irreversibility was an
appropriate reason for DNAR, 18 specifically
mentioned that the patient’s pre-morbid condition
was an important consideration, and 27 considered
co-morbidities to be important influences on their
decision-making. Quality of life (QoL) was a key
factor in making DNAR decisions for 42 (18%)
respondents (Box 1, Quotes 4(d), 1126). About one
third of these respondents did not provide further
information, but another third referred to pre-morbid
or pre-admission QoL, and for the remaining third,
expected post-resuscitation QoL was the key factor.
Forty-three respondents (18%) mentioned that
the patient’s wishes were important (Box 1, Quotes
4(d), 1247).
Table 2 shows agreement levels for questions
regarding preferred clinical practice for DNAR
decision-making. Around half of the SpRs who
responded agreed that they found it uncomfortable
to discuss DNAR with the patient. About half of the
respondents agreed that they had had different
opinions from their consultants regarding DNAR at
some point, and that they were better skilled than
their colleagues from other specialities in making
such decisions. Just over half of the respondents
agreed that their decision varied depending on
whether or not the patient in question was under
their care. The majority (84%) disagreed that
decision-making with regard to DNAR decision
should be left to consultants alone. These findings
are particularly interesting because consultants
in the NHS in the UK are not only independent
practitioners who hold the responsibility for
management decisions, but also educational super-
visors of their juniors, including SpRs. A fifth of the
respondents were concerned about complaints
being made against them over DNAR decision-
making. Over half disagreed that relatives should
only be informed about decisions but not actively
involved in the decision-making. Furthermore, half
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Box 1. Quotations from the responses to questions 4 (a), (b), (d) and (e)
4 (a) What single factor would make DNAR decisions easier and why?
Greater patient/public awareness of outcomes of resuscitation and what DNAR means (i.e. does not mean withdrawal of
active treatment)
1113 A public debate to explain the chance of success, what resuscitation is, and why it is often futile.
1200 If the issue were routinely raised with the patients outside the acute situation. If everyone understood that DNAR
does not mean ‘not for active treatment’.
Advanced directives/Living wills
1119 Discussing this thorny issue of DNAR with a vulnerable, ill patient often compounds their existing worries that ‘the
doctor believes I’m going to die because he is discussing resuscitation issues with me’. Directives made while ‘healthier’
may be more neutral and helpful to final decision-making.
Part of the standard procedure on admission
1097 Asking every patient who walks through the A/E door whether or not they would want resuscitation (not just the
people who are frail), i.e. it should be part of the process and universal.
DNAR decisions based on clinical judgement/medical decision-making, individual clinician, teams, or ICU staff
1168 A wider appreciation of likely successful outcome stratified (for example) by disease, concomitant disease, etc.
This would allow us to give patients and relatives a more concrete idea of the likelihood of long-term survival.
4 (b) Which document/guideline would you recommend as guidance for DNAR decision for your colleagues?
Recommendations
1102 The ‘Duties of a doctor’ booklet, but sensible discussion with experienced responsible clinician is usually better
than general written guidelines.
1244 There are various things to take into account: (i) patient wishes; (ii) underlying medical problems; (iii) quality of
life; (iv) chances of successful resuscitation; (v) decision made with colleagues and relatives; (vi) age.
Insufficiencies of guidelines
1014 I know the guidelines well, and I am not sure I would recommend them. The joint resuscitation/RCN guidelines
are very contradictory, even within one sentence sometimes.
1113 None. There is no good guidance that covers the difficulties, some documents contradict themselves.
Concern over complaint/litigation
1109 Follow local policies: then the Trust has to support you if things go wrong.
4 (d) In your current clinical practice, what is the single most influencing factor in making DNAR decisions?
Likelihood of success
1002 The main factor is the likely outcome. I see it as a medical treatment. If it’s not going to work, don’t do it.
1103 Outcome/survival probability. I always ask myself the question ‘Should this patient be resuscitated?’ or ‘Will they
survive an ITU stay?’
Medical condition
1141 Whether the underlying disease process is reversible and a resuscitation attempt is likely to have a positive
outcome.
Quality of life
1126 Quality of life before and after.
Patient’s wishes
1247 Patient’s own wishes.
4 (e) Do you see any change in future regarding DNAR decision making? If so, what?
1224 Resuscitation forms completed on admission for all patients giving patient wishes/status.
1189 More open discussion about subject. Patient makes decision in advance.
1242 More use of advance directives, more open approach by clinicians and involving the patient earlier.
1253 Probably more patient involvement in decision-making, consequently with more CPR attempts that are almost
certainly going to be unsuccessful.
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Table 1 Extent to which DNAR decisions were based on various practices
Practice Respondents 425% of
the time
26–50% of
the time
51–75% of
the time
576% of
the time
Seeking the patient’s opinion on DNAR decisions 233 (99%) 119 (51%) 67 (29%) 24 (10%) 23 (10%)
Seeking a relative’s opinion as proxy for the patient 230 (98%) 60 (26%) 64 (28%) 31 (14%) 75 (33%)
Discussing the decision with a relative 232 (99%) 9 (4%) 39 (17%) 38 (16%) 146 (63%)
Basing the decision primarily on expected quality of life after resuscitation 230 (98%) 74 (32%) 55 (24%) 26 (11%) 75 (33%)
Basing the decision primarily on likelihood of successful resuscitation 231 (98%) 26 (11%) 41 (18%) 30 (13%) 134 (58%)
Making partial DNAR decisions 232 (99%) 214 (92%) 14 (6%) 4 (2%) 0
Table 2 Levels of agreement with various statements
Statement Respondents Strongly
agree
Agree Neutral Disagree Strongly
disagree
I find it uncomfortable discussing DNAR with patients 234 (99%) 32 (14%) 89 (38%) 38 (16%) 59 (25%) 16 (7%)
I sometimes disagree with the decision made by my consultant 235 (100%) 5 (2%) 121 (52%) 44 (19%) 50 (21%) 15 (6%)
I think I am better at making DNAR decision than my colleagues from other medical specialties 234 (99%) 27 (12%) 93 (40%) 64 (27%) 47 (20%) 3 (1%)
My decision can vary depending on whether the patient is directly under my care 234 (99%) 27 (12%) 103 (44%) 38 (16%) 52 (22%) 14 (6%)
I worry about getting complaints about CPR 235 (100%) 9 (4%) 39 (17%) 66 (28%) 98 (42%) 23 (10%)
I believe relatives should only be informed about decisions but not involved in decision-making 234 (99%) 27 (12%) 44 (19%) 29 (12%) 110 (47%) 24 (10%)
I think more patients should be made not for resuscitation 234 (99%) 26 (11%) 91 (39%) 56 (24%) 51 (22%) 10 (4%)
DNAR decisions should be made by consultants only 235 (100%) 2 (1%) 13 (6%) 22 (9%) 145 (62%) 53 (23%)
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agreed that more patients should be designated
DNAR, in comparison to only a quarter who
disagreed. A more detailed analysis was conducted
to see whether there was any association between
having experience with arrest situations and having
a strong view on this issue. Respondents who had
<7 years of experience (UK experience or experi-
ence in holding arrest bleep) were more likely
to give a neutral response to the statement that more
patients should be designated DNAR, than those
with 57 years of experience, who were more likely
to agree (
2
¼ 6.006, p ¼ 0.05).
When asked to detail the single factor that would
make DNAR decisions easier and why, 54 (23%)
of the respondents felt that greater patient/public
awareness of the outcomes of resuscitation and what
DNAR means (i.e. that it does not mean withdrawal
of active treatment) would make decisions easier.
Just under a fifth of the respondents felt that
Advanced Directives or Living Wills (43, 18%)
would make DNAR decision-making easier, as
would a Trust policy including a standard procedure
at admission to record patients’ wishes on DNAR
(40, 17%). Some respondents felt that DNAR
decision-making should be based on clinical judge-
ment/medical decision-making either by individual
clinician, teams or intensive care unit staff
(25, 11%). Discussion of the issues around DNAR
away from the clinical environment would improve
DNAR decision-making for some respondents
(13, 6%), e.g. consideration of DNAR issues before
the patient is critically ill, prior to hospital admis-
sion, in a non-hospital environment such as
with the GP. Other factors mentioned by fewer
respondents included: having more time with
patients, early discussion with patients and relatives,
consensus between patient, relatives and staff,
reduced power of next of kin, more realistic guide-
lines, adopting medical futility and less litigation
(Box 1, Quotes 4(a)).
Interestingly, when asked what, if any, changes
they saw in the future regarding DNAR decision-
making, the SpRs’ responses indicated that these
factors that would make decision-making easier
were also the kind of changes that they could see
coming. This said, 31 (13%) respondents did not
respond and 20 (9%) said they did not see any
changes. Among those who did see changes in the
future (Box 1, Quotes 4(e)) greater patient involve-
ment was the biggest single change predicted
(65, 28%); this included asking all patients their
wishes at admission or early during the hospital stay,
and discussion of DNAR with patients. Also,
29 (12%) thought that there would be increased
discussion and awareness about DNAR and CPR
generally amongst the public, relatives, patients and
health professionals. The involvement of advocates,
in particular relatives, when patients are unable to
give their wishes was seen as a possible change
by 16 (7%) respondents. More use of Advance
Directives or Living Wills was mentioned by
23 (10%) respondents. Twenty-one respondents
(9%) mentioned guidelines, with some indicating
that there were problems with current guidelines,
others suggesting that new, better or more formal
guidelines were required, and finally others simply
mentioning that guidelines needed to be used,
or that everyone needed to be more aware of
the guidelines. Twenty (9%) thought that in the
future there would be fewer DNAR decisions and,
consequently, more CPR attempts. The consensus
here appeared to be that this would lead to more
inappropriate resuscitation or automatic resuscita-
tion of everyone. Nineteen (8%) said that in the
future DNAR decisions would be left to doctors,
with 10 of these respondents specifically mentioning
consultant-led decision.
Discussion
This survey confirms that geriatric medicine trainees
are extensively involved in both resuscitation efforts
and decisions surrounding withholding such
resuscitation. The response rate of 62% is not
surprising in a population that is highly mobile,
leading to inaccuracies in mailing lists. With
a response rate of about two-thirds of higher
specialist trainees in one medical subspecialty, this
survey should not be viewed as a census of
experience, clinical practice and attitude towards
DNAR decision-making amongst trainees in higher
medical education in the UK. However, the clinical
experience of the respondents had a median of
8 years, reflecting the present day SpR grade
experience across all medical specialities. Studying
a selected group as we did in this survey is not
necessarily a limitation. On the contrary, their
specific patient population may give them insights
less available to other specialties. Our survey also
provide useful information as to how we might
help promote experience and training of SpRs with
regard to CPR and DNAR decisions.
In a study by Einav and colleagues of 79 practi-
tioners on general medical wards in Jerusalem,
Israel,
12
survey participants rarely discussed DNAR
orders with patients and their next of kin, tending
instead to confer DNAR based on their personal
value judgments rather than patient preferences.
They also performed CPR when no pathophysio-
logical benefit was expected, and performed
limited resuscitation efforts frequently, which were
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hypothesized as efforts to circumvent the need for
DNAR orders. The authors highlighted the important
differences between the ideal guidelines such as
joint UK guidance
8
and existing practice, in end-of-
life decision-making in their cultural setting.
Usefulness of national and local guidelines
A high percentage of respondents stated that the
Trusts in which they are currently working had
DNAR guidelines. However, one third of them did
not find such policies helpful. There are some
possible reasons why such guidelines are of limited
value. Florin cautioned, for example, that a policy
that makes patient consent a universal requirement
of DNAR orders is likely to fail.
13
Opinions
regarding DNAR decisions often differ between
decision-makers
14
and this also makes rigid guide-
lines likely to fail.
Almost a third of respondents did not answer
the question on which document/guideline they
would recommend. Lack of response to this ques-
tion could be interpreted in a number of ways: e.g.
unfamiliarity with available guidelines, not valuing
the guideline used in their Trusts, or feeling that
guidelines alone did not provide all the advice and
information required to make DNAR decisions in
practice. It may be that despite there being a range
of guidelines in use, no one guideline is considered
to be the gold standard, and some respondents
pointed out inadequacies. The lack of response may
also suggest that these SpRs do not solely base
DNAR decisions on a written document, but
combine it with other decision-making techniques,
such as their own clinical judgement, the advice of
their senior clinicians and the local Trust position
on DNAR.
Current experience and involvement
The fact that the experience of the respondents
extended to making decisions about patients who
are not under their care, including younger patients,
may reflect the nature of the training involving
general medicine and out-of-hours middle-grade
cover for the whole hospital. It is possible that
DNAR decisions are not being taken early enough
by a patient’s own team, leaving on-call doctors
to make them out of hours. The need to make
DNAR decisions on patients outside the usual team
structure has implications for training, and may
lead to trainees’ anxiety about increased chance of
medico-legal challenge. This may have contributed
to the concern about getting complaints, and also
may have influenced the decision-making in over
half of the respondents, who said that they would
agree or strongly agree to the statement that their
decision can vary depending on whether the patient
is under their care or not.
Discussion with patients and relatives
We found a huge diversity of clinical practice
among the respondents. There appeared to be
tension between medical futility and patients’ or
close relatives’ unrealistic expectations, causing
problems in reaching a unanimous decision.
While some ethicists hold the opinion that patients
should always be offered CPR, a less extreme view is
that it is within the legitimate professional role
of doctors to define the absence of medical benefit,
but not to make quality-of-life decisions without
involving the patient.
15,16
Unfortunately, our study
suggests that even at specialist registrar level in
a speciality which routinely has to deal with DNAR
issues, doctors are still uncomfortable discussing
end-of-life care issues with their patients, and are
more likely to discuss DNAR decisions with relatives
than with patients. This highlights the need for
support and further training in this area. Greater
public awareness and involvement of patients in the
decision-making process, including use of Advance
Directives, was seen as one way forward. There
was a suggestion amongst some respondents that
early discussion with patients as a standard part
of the admission process might make discussion
of DNAR issues easier, as such discussion would
be expected by all patients as soon as they arrive at
hospital.
In critically ill patients, when the patient’s opinion
cannot be sought for various reasons, doctors either
seek proxy decision from close relatives or make
CPR decisions based on perceived quality of life of
their patient.
Estimating quality of life and
success of CPR
Although there has been an attempt to differentiate
between unacceptable pre-arrest quality of life and
where quality of life after CPR is unacceptable,
17
there is little evidence to help physicians predict
which patients will undergo a change in quality of
life due to CPR. Physicians often rely on assumed
quality of life of their patients in their DNAR
decision, but unfortunately, tend to underestimate
it.
18
Furthermore, although patients predict that
both their physicians and family members would
accurately represent their wishes,
18
doctors and
relatives are very poor at estimating both their
patients’ quality of life and their wishes.
19–21
While
some patients do not want to be involved in
such decisions, most patients would like more
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communication with their doctors about resuscita-
tion issues.
22,23
Approximately one third of the
respondents would primarily base their decision on
the perceived quality of life of the patient after
resuscitation at least 50% of the time. This practice,
therefore, could potentially be improved with
increasing awareness of the literature among the
trainees.
Varying opinions among doctors in
making DNAR decisions
Wagg and colleagues reported that doctors who had
attended more than 25 CPR attempts were better
at making realistic DNAR decisions, and that there
was an inverse relationship between expectation of
survival and number of arrests attended.
24
DNAR
recommendations also vary with medical speciality,
and with years of training and experience.
14
In this
study, partial DNAR decisions were made by some
of our respondents, but not by others. Over half had
dissenting views on decisions made by their
consultants at some point. Considering that the
SpRs are fairly senior team members, there is an
intriguing possibility that the trainers (consultants)
are making inappropriate CPR orders or not making
appropriate DNAR orders for various reasons
including the fear of litigation, which should be
examined in future studies. Worryingly, more than
half of the respondents stated that their practice
could vary depending whether the patient is under
their care or not, which gives some insight into
the difficulties that a decision-maker encounters
outside the structure of the clinical team.
Appropriate training and support may be the way
forward to improve the clinical practice and
experience of trainees in dealing with such delicate
issues.
It could be argued that the large diversity in their
opinions was related to the sociodemographic
characteristics such as age, sex and religious
beliefs of the SpRs. We deliberately did not collect
any identifiable data from the participants, to
assure complete confidentiality. The major draw-
back of this approach is that we are not able
to provide such data about the respondents, or
correlate these factors with their responses.
Nevertheless, the primary aim of our study was to
examine the experience, practice and views of
higher specialist trainees in the UK on DNAR
decision-making, regardless of their gender, racial
or religious background.
One limitation of the survey is that the questions
used were not validated. This made us unable to
report one of the questions in this report, due to
the ambiguity of the question (question 4c).
However, the respondents did not appear to
encounter any major issue in answering the
remaining part of the questionnaire. This is probably
because we have used standard validated methods,
e.g. level of agreement, with which all higher
trainees are familiar.
A sea of uncertainty?
Our study provides a snapshot view of current
experience and involvement in DNAR decision-
making of higher specialist trainees in a major
medical subspecialty. Although our study cannot
be regarded as representative of the situation
among all higher specialist trainees, respondents in
our survey are fairly representative of this grade in
terms of clinical experience, and may be more
familiar with this issue compared to SpRs in other
subspecialties.
Our results suggest that even in a speciality which
commonly encounters such ethical issues, SpRs are
being tossed around in a sea of uncertainty. There is
considerable inconsistency in opinion and practice
in the DNAR decision-making process among these
SpRs, and many do not find the available guidelines
to be particularly helpful. Furthermore, these SpRs
find it stressful to speak to patients about DNAR
decisions, and they sometimes disagree with their
consultants.
Various issues highlighted in this report, such as
inadequacies of guidelines, stressful nature of
discussion the DNAR issue with patients and
relatives, and wide variation in the clinical practice
among trainees, indicate that there is potential
for improvement in further training and support
from senior colleagues. Training and education in
medico-legal aspects and increased awareness of
the literature surrounding DNAR issues may also
improve SpRs’ confidence in their decision-making
process. It may be possible to adopt well-established
methods used in some medical specialities (e.g.
debriefing), particularly when SpRs are faced with
traumatizing personal experience which could
potentially influence their clinical practice in the
future.
On the other hand, professional guidelines could
also be clearer and more user-friendly. Some
respondents pointed out inadequacies in some of
the currently available guidelines. Continual review
and user involvement may improve the standard
and applicability of future CPR/DNAR guidelines.
However, it would be impossible to provide clear
guidance on every possible clinical scenario, and
this kind of detailed approach has to be balanced
with the generalizability of guidance and
some clinical freedom for the practitioner.
698 P.K. Myint et al.
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Page 8
Further research is required to help formulate
training initiatives and develop effective training
methods for SpRs, and to find the most effective way
to educate the public regarding DNAR decision-
making. Ideally this should involve a partnership
between the public, ethical experts, legal experts
and the front-line clinicians, including trainees
themselves.
Acknowledgements
We would like to thank the former Honorary
Secretary of the British Geriatrics Society (BGS),
Dr Kevin Kelleher, and Ms Recia Atkins from the
BGS office for giving permission to conduct this
national survey on trainee members of the BGS, and
Mrs Marlene Gabriel and Mr Tony Winhall from
Norfolk and Norwich University Hospital for their
assistance with the project. We gratefully acknowl-
edge the participants in this questionnaire. We
also would like to acknowledge the contribution
of one of the co-authors of this paper (DAH) who
contributed on behalf of the East of England
Research Development & Support Unit. Some
of the data were presented in British Geriatrics
Society Autumn Meeting, 6–8 October 2004 as
a poster entitled ‘Do not attempt resuscitation
(DNAR) decision making and trainees in Geriatric
Medicine’, and published as an abstract in Age and
Ageing, July 2005.
References
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Appendix: Questionnaire survey on ‘Do Not Attempt Resuscitation’
decisions
1. About your experience with cardiac arrests and DNAR decisions
(a) How many years have you been practising in the UK? (Please include PRHO* year if it is applicable).
(b) During this practice, how many years have you held a crash bleep
y
?
(c) Are you asked to make DNAR decisions for patients who are not under your team’s care? (commonly/sometimes/
rarely/never).
(d) Do you ever make DNAR decisions on younger adults (18 to 55 years of age)?
(e) Do you have a trust policy for DNAR in your hospital? If yes, do you find it helpful?
2. About your current practice with DNAR decisions (Please answer by approximate percentages, e.g. 20% of
decisions)
(a) How often do you seek the patient’s opinion on DNAR decisions?
(b) How often do you seek the relative’s opinion as proxy for the patient?
(c) How often do you discuss your decision with a relative?
(d) How often do you base your decision primarily on expected quality of life after resuscitation (determined by you)?
(e) How often do you base your decision primarily on likelihood of successful resuscitation?
(f ) How often do you make partial DNAR decision? [e.g. for DC shock if shockable rhythm but not for CPR if PEA(EMD)]
3. About your feelings regarding DNAR decisions (SA ¼ strongly agree, A ¼ agree, N ¼ Neutral, D ¼ disagree,
SD ¼ strongly disagree)
(a) I find it uncomfortable discussing DNAR with patients.
(b) I sometimes disagree with the decision made by my consultant.
(c) I think I am better at making DNAR decision than my colleagues from other medical specialities.
(d) My decision can vary depending on whether the patient is directly under my care.
(e) I worry about getting complaints about CPR decisions.
(f) I believe relatives should only be informed about decisions but not involved in decision-making.
(g) I think more patients should be made not for resuscitation.
(h) DNAR decisions should be made by consultants only.
4. About your opinion/practice in future (Please describe in 50 words or less. Continue overleaf if necessary)
(a) What single factor would make DNAR decisions easier and why?
(b) Which document/guideline would you recommend as guidance for DNAR decision for your colleagues?
(c) Briefly describe your worst or most memorable experience of DNAR (data not reported here).
(d) In your current clinical practice, what is the single most influencing factor in making DNAR decisions?
(e) Do you see any change in future regarding DNAR decision making? If so, what?
*PRHO, Pre-registration House Officer (equivalent to house officer/internship).
y
The ‘crash bleep’ is a bleep held by
several members of the medical on-call team during their duty. It is activated by a cardiac arrest, and the persons holding
the bleep need to attend the cardiac arrest call immediately. A typical cardiac arrest team consists of a medical registrar
(SpR) as the team leader, a medical senior house officer (SHO), a medical junior house officer, a resuscitation officer, an
anaesthetist (either SHO or SpR) who can perform intubation, a nursing sister, a senior nurse and two porters.
700 P.K. Myint et al.
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    • "I'm not sure that I know what that means' (Williams & Sibbald 1999, p. 743). However, it would be impossible to give clear guidance on every possible clinical scenario, and this kind of detailed approach has to be balanced with the generalizability of guidance and some clinical freedom for practitioners (Myint et al. 2006). As an uncertain situation, the nurses wondered whether to advocate for patients or give support to their physician colleagues. "
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  • [Show abstract] [Hide abstract] ABSTRACT: A number of studies have explored doctors' views and experiences of cardiopulmonary resuscitation (CPR), but to our knowledge there has been no research to identify the information that doctors take into account when they make decisions about CPR. To investigate factors that influence decisions about CPR. Qualitative study involving six focus groups with 17 doctors and four medical students in Leicester, UK. Doctors and medical students considered a number of factors important when making decisions about CPR-namely, the patient's diagnosis, prognosis, age, quality of life, the opinions of doctors and other medical staff, and the wishes of patients and relevant others. The relative importance of each of these factors varied significantly and was influenced by the doctors' own beliefs and values. Doctors would benefit from greater support for their decision making in relation to resuscitation to reduce variability in clinical practice and to promote appropriate patient care. Identification of factors that influence doctors' individual beliefs, attitudes and values towards resuscitation and improvement in the quality of patient communication may help to guide policy in this area.
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