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

Yuen, Jimmy; Reid, M. Carrington; Fetters, Michael D.

doi:10.1007/s11606-011-1632-x

Cited by 109 publications

(101 citation statements)

References 73 publications

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“…Some believed that diagnostic tests shouldn't be ordered when a patient was DNR [2]. One Study surveyed primary and cross-covering residents of patients with DNR orders and found that residents intended to withhold a variety of other therapeutic interventions, that in half of these instances there was no chart documentation to that effect, and that there was little agreement between primary and cross-covering residents regarding which therapies to withhold [11,12].…”

Section: Discussionmentioning

confidence: 99%

“…Teaching skills in breaking bad news and managing family conflicts are important to prepare future providers to assist patients and families navigate through the complex and difficult decisions surrounding resuscitation decisions. [2].…”

Section: Discussionmentioning

confidence: 99%

“…In the mid-1970s, hospitals began to implement policies on DNR orders. These policies served to establish procedures for writing DNR orders [2]. Research showed that about 5% of patients who required advanced cardiac life support (ACLS) outside the hospital and 15% of patients who required ACLS while in the hospital survive [3,4].…”

Section: Introductionmentioning

confidence: 99%

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Medical Residents’ Practices and Perceptions toward Do-Not-Resuscitate (DNR) Order

Albugami¹,

Bassil²,

Laudon³

et al. 2017

J Palliat Care Med

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The knowledge and implementation skills of the DNR order amongst physicians in training appear to be quite variable. Few studies had assessed residents' views on this complex topic. Our objective was to describe the medical residents' practices and perceptions toward DNR order. A 26 question survey was distributed to medical residents during the academic day activity. Only 56 residents completed the questionnaire (75% response rate). 61.40% of the residents understood the definition of DNR order. 85.96% thought physicians shouldn't order diagnostic tests for DNR patients and 92.98% thought physicians shouldn't give blood products and antibiotics to DNR patients. 45.61% thought DNR order would lead to poor care. 36.84% thought physician alone should decide about the DNR decision. 45.61% answered that DNR order never discussed with patients. 64.91% answered that consultant discussed DNR order with patients. 42.11% of residents were involved in the discussion of DNR order. 66.67% answered that time to decide about the DNR order on day of admission. 42.11% answered there was variation between consultants regarding the care of DNR patient. 43.86% answered there was variation in the clinical care before and after DNR order was placed. 87.72% thought here was a need for formal training in DNR discussion. 68.42% didn't know if KFSH and RC had clinical guidelines for DNR patients care. Conclusion:(1) Majority of the residents had misunderstanding regarding DNR patient care and comfortable care. There is a need for developing a structured residency program curriculum to address resident skills in end-oflife care. (2) Encouraged discussions DNR issues in the outpatient setting could prevent unwanted resuscitation in the acute setting. (3) Efforts are needed to increase patients and their families' awareness about the meaning of DNR order. (4) There is a need to unify and improve quality of care provided to DNR patients by developing specific strategies within a framework of goals of care.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Medical Residents’ Practices and Perceptions toward Do-Not-Resuscitate (DNR) Order

Albugami¹,

Bassil²,

Laudon³

et al. 2017

J Palliat Care Med

View full text Add to dashboard Cite

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“…3 Recent studies report that patients receive inadequate information and are unprepared for end-of-life decision-making. [11][12][13][14] Counseling by physicians can also vary greatly in style and content, leading to inconsistencies in the quality of the decisionmaking process. [4][5][6]15,16 Our group, the Video Images of Disease for Ethical Outcomes (VIDEO) Consortium, has developed and evaluated several decision support tools to assist patients with end-oflife decisions.…”

Section: Introductionmentioning

confidence: 99%

A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients

et al. 2015

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BACKGROUND: Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. OBJECTIVES: We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. DESIGN: This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. PARTICIPANTS: One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51 % were women. INTERVENTION: Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N=75) or control arm (usual care) (N=75). MAIN MEASURES: The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). RESULTS: Intervention participants (vs. controls) were more likely not to want CPR (64 % vs. 32 %, p <0.0001) and intubation (72 % vs. 43 %, p<0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57 % vs. 19 %, p<0.0001) and intubation (64 % vs.19 %, p<0.0001) by hospital discharge, documented discussions about their preferences (81 % vs. 43 %, p<0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p<0.0001).CONCLUSIONS: Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers. Trial registration: Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.

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“…4,5 Advance care planning seeks to prepare patients and surrogates for making in-the-moment medical decisions. 6 There also exist excellent guidelines for approaching patients and their families at the end of life.…”

Section: Don't Smoke Eat Rightmentioning

confidence: 99%

Educating our Patients about Life and the End of Life: Toward a Pedagogy of Dying

Ventres

2014

The Journal of the American Board of Family Medicine

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There is an extensive literature on how physicians can best educate their patients about living healthierone might call it a "pedagogy of living." In this essay, I suggest that physicians develop a "pedagogy of dying" for their adult patients: educating them about how they can approach death with some measure of grace and dignity, as consistent with their wants as possible, and cognizant of the final reality we all face. This process happens in the ambulatory settings as part of ongoing care and precedes any serious illness or the crisis of hospitalization. I draw on known models for communicating effectively, my own practice experience, and the disciplines of palliative care and bioethics in asking physicians to consider developing such a "pedagogy of dying," a kind of anticipatory guidance toward aging, infirmity, and, ultimately, death. As physicians, we make a great number of recommendations to our adult patients about how they should live. These recommendations collectively create a "pedagogy of living": suggestions for living healthier lives. What I propose here, however, is for physicians to develop a "pedagogy of dying": a way of educating patients about how to approach their deaths with some measure of grace and dignity, as consistent with their wants as possible, and cognizant of the final reality that we all face.Much has been written-prudently and with sensitivity-about advance directives, physician orders for life-sustaining treatment, and do-not-resuscitate orders, 1-3 including suggestions on how to approach these issues as structural concerns embedded in the culture of medical practice.4,5 Advance care planning seeks to prepare patients and surrogates for making in-the-moment medical decisions. 6 There also exist excellent guidelines for approaching patients and their families at the end of life.7 Still, most discussions about death and the desired clinical response come quite late in the course of patients' lives-often too late for sensible dialogue to occur.When the end of life looms inevitable and not just as an abstract awareness, a whole host of social and emotional preoccupations overwhelm patients, families, and clinicians alike. It is important for us as physicians to proactively aid patients before the end of life to ameliorate the fear, loneliness, and uncertainly that often accompanies the dying process, especially in today's fragmented medical environment. Beyond the necessity of knowing know what end-of-life interventions are desired or appropriate, we have a responsibility to help people explore and come to terms with their own mortality well before it is "their time."There is ample space in the academic literature that describes communicative tools given to adeptly practicing a "pedagogy of living," 8 including several models for structuring clinical conversations and the dynamics of interpersonal engagement. 9,10

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

Cited by 109 publications

References 73 publications

Medical Residents’ Practices and Perceptions toward Do-Not-Resuscitate (DNR) Order

Medical Residents’ Practices and Perceptions toward Do-Not-Resuscitate (DNR) Order

A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients

Educating our Patients about Life and the End of Life: Toward a Pedagogy of Dying

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