How, When and Where to Discuss Do Not Resuscitate: A Prospective Study to Compare the Perceptions and Preferences of Patients, Caregivers, and Health Care Providers in a Multidisciplinary Lung Cancer Clinic (original) (raw)
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PLOS ONE, 2018
Introduction In cancer care, do-not-resuscitate (DNR) decisions are made frequently; i.e., decisions not to start the heart in the event of a cardiac arrest. A DNR decision can be a complex process involving nurses and physicians with a wide variety of experiences and perspectives. Previous studies have shown different perceptions of the DNR decision process among nurses and physicians, e.g. concerning patient involvement and information. DNR decisions have also been reported to be unclear and documentation inconsistent. Objective The aim was to investigate how important and how likely to happen nurses and physicians considered various aspects of the DNR decision process, regarding participation, information and documentation, as well as which attributes they found most important in relation to DNR decisions. Methods A descriptive correlational study using a web survey was conducted, including 132 nurses and 84 physicians working in hematology and oncology. Results Almost half of the respondents reported it not likely that the patient would be involved in the decision on DNR, and 21% found it unimportant to inform patients of the DNR decision. Further, 57% reported that providing information to the patient was important, but only 21% stated that this was likely to happen. There were differences between nurses and physicians, especially regarding participation by and information to patients and relatives. The attributes deemed most important for both nurses and physicians pertained more to medical viewpoints than to ethical values, but a difference was found, as nurses chose patient autonomy as the most important value, while physicians rated non-maleficence as the most important value in relation to DNR decisions.
End-of-Life Care in Patients With Lung Cancer*
Chest, 2003
Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.
The perceptions of do-not-resuscitate policies of dying patients with cancer
Psycho-Oncology, 2008
Patients in hospitals must authorize do-not-resuscitate (DNR) orders or the default cardiopulmonary resuscitation (CPR) occurs. Using discursive analysis, we examined the speech of 28 cancer patients, judged as within 3 months of death, to determine how they justified preferences for DNR orders. Most saw these as a positive outcome of not interfering with a natural death with the decision being personal and the legal right of a competent autonomous person. If surrogates were required, they needed knowledge of the medical facts and the patient's wishes. The doctor was crucial, while family although likely to be supportive may be burdened by the responsibility. Some favored an early DNR discussion, but the majority favored a later discussion when it was applicable. At interview, 58% patients had a DNR order, rising to 82% by the time of death. Written orders were favored, yet 9 of 21 who did not want CPR had no DNR order. Hope was mentioned spontaneously by 25 patients, both as a thing over which patients had little control and as the desire of a positive future outcome. If doctors' and patients' assessments of eligibility for DNR orders do not coincide, the process and documentation of decision-making needs revision.
Translating into Practice Cancer Patients’ Views on Do-Not-Resuscitate Decision-Making
Cancers, 2016
Do-not-resuscitate (DNR) orders are necessary if resuscitation, the default option in hospitals, should be avoided because a patient is known to be dying and attempted resuscitation would be inappropriate. To avoid inappropriate resuscitation at night, if no DNR order has been recorded, after-hours medical staff are often asked to have a DNR discussion with patients whose condition is deteriorating, but with whom they are unfamiliar. Participants in two qualitative studies of cancer patients' views on how to present DNR discussions recognized that such patients are at different stages of understanding of their situation and may not be ready for a DNR discussion; therefore, a one-policy-fits-all approach was thought to be inappropriate. To formulate a policy that incorporates the patient's views, we propose that a standard form which mandates a DNR discussion is replaced by a "blank sheet" with instructions to record the progress of the discussion with the patient, and a medical recommendation for a DNR decision to guide the nursing staff in case of a cardiac arrest. Such an advance care directive would have to honor specifically expressed patient or guardian wishes whilst allowing for flexibility, yet would direct nurses or other staff so that they can avoid inappropriate cardiopulmonary resuscitation of a patient dying of cancer.
Do Not Resuscitate (DNR) Order among Terminally Ill Patients with Cancer: A Position Statement
End-of-life (EOL) care takes an important place in critical care settings. Of it, one of the most serious and arguable decision is the Do Not Resuscitate (DNR) order. The DNR is a legal order written by a licensed physician in consultation with the patients or their surrogate decision makers, in which the cardiopulmonary resuscitation (CPR) is withhold at the time of cardiac or respiratory arrest. Many studies reported that many inpatient deaths had a DNR order. The purpose of this position statement paper is to present proponents and opponents' viewpoints regarding the DNR orders for terminally ill patients with cancer. Proponents of the DNR order reported that it is a form of treatment that protects patients' rights, and allows the terminally ill cancer patients to die peacefully without undergoing futile resuscitation attempts. Opponents of the DNR order are concerned with the protection and preservation of life of the terminally ill cancer patients. The current author is against the DNR order based on the patients' right for sanctity of life, and the Islamic views of human life.
Medical Oncology Taskforce on Palliative and Sup
2003
BACKGROUND AND METHODS. In part of a quality improvement program, the European Society of Medical Oncology (ESMO) surveyed its membership regarding their involvement in and attitudes toward the palliative care (PC) of patients with advanced cancer. RESULTS. Of 895 members who responded, 82.5% were European and 12.1% were American. Sixty-nine percent of respondents reported that patients with advanced cancer constituted a major proportion of their practice; for 22% of respondents, patients with advanced cancer constituted most of their practice. Only a minority of respondents collaborated often with a PC care specialist (35%), a palliative home care service (38%), an in-patient hospice (26%), or a psychologist (33%). In response to questions regarding specific involvement in PC clinical tasks, respondents were involved more commonly in treating physical symptoms, such as pain (93%), fatigue (84%), and nausea/emesis (84%), than in managing psychological symptoms and end-of-life care issues, such as depression/anxiety (65%), existential distress (29%), or delirium (12%). Forty-three percent of respondents reported that they directly administered end-of-life care often, and 74% reported that they derived satisfaction from their involvement in end-of-life care. Overall, 88.4% of respondents endorsed the belief that medical oncologists should coordinate the end-of-life care for their patients, but a substantial minority (42%) felt that they were trained inadequately for this task. Positive attitudes toward PC were correlated highly with the degree of direct involvement in PC practice. Practitioners in private practice or teaching hospitals had substantially more positive attitudes regarding PC compared with physicians based in comprehensive cancer centers (P Ͻ 0.05). Although most of the responding medical oncologists expressed positive views regarding their involvement in the PC of patients with advanced cancer and dying patients, 15% of respondents had pervasively negative views. CONCLUSIONS. Most ESMO oncologists recognize the importance of PC and supportive care for patients with advanced cancer. Despite this, many are prepared inadequately for these tasks, and actual participation levels commonly are subop
Cancer, 2010
BACKGROUND:Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit.Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit.METHODS:A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis.A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis.RESULTS:Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P = .0005), nausea of 2 (0-7) versus 1 (0-4, P = .05), and dyspnea of 1 (0-5) versus 4 (0-7, P = .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P = .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P = .002) and with no advance directives (OR, 2.94; P ≤ .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P ≤ .0001).Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P = .0005), nausea of 2 (0-7) versus 1 (0-4, P = .05), and dyspnea of 1 (0-5) versus 4 (0-7, P = .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P = .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P = .002) and with no advance directives (OR, 2.94; P ≤ .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P ≤ .0001).CONCLUSIONS:DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions. Cancer 2010. © 2010 American Cancer Society.DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions. Cancer 2010. © 2010 American Cancer Society.
International Journal of Research Studies in Medical and Health Sciences
In worst cases, there may even be a potential harm if patients with fatal and irreversible diseases are kept on a full-code status, undergoing painful and dehumanizing procedures like chest compressions, intubations, and mechanical ventilations, even when their clinical conditions imply that resuscitation efforts will not bring ABSTRACT Cardiopulmonary resuscitation can be medically futile and lead to prolonged suffering in some patients with disseminated malignancies. The aim of this study is to identify physicians' awareness, knowledge, and attitudes towards performing or withholding Cardiopulmonary resuscitation in cancer patients in the Middle East and the process they preferred for discussing this with the patients and families. A crosssectional survey was used and sent to physicians from different specialties in Comprehensive Cancer Center. There was a 68% (51 out of 75) response rate for the survey; the majority(82%) were males. 84% identified the discussion of resuscitation with patients and relatives as important, and 98% stated that they would prefer not to resuscitate patients with metastatic disease where the resuscitation would be medically futile. More than half 57 % wished to discuss resuscitation with both patients and relatives, together and 12% (6) stated that patients alone should be involved in this discussion. The best time for resuscitation discussion is when the patient is conscious and oriented by 86% (n=43) of responders; 10.0 %(n=5)) wished to wait till the patient was comatose and requirement of resuscitative measures were imminent. Less than half the responders (43%) were aware of hospital policies regarding resuscitation. Most physicians in our study were aware of the importance of resuscitation discussion in cancer patients but varied in their approach as to when and to whom they should have these discussions. A small minority still believed that resuscitation should continue regardless of medical futility and most were not aware of hospital policies. This study highlights the importance of education and further training in the discussion about cardiopulmonary resuscitation for physicians involved in cancer care.