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

Abstract

Background: Do Not Resuscitate (DNR) is a significant but challenging part of end-of-life discussions when dealing with incurable lung cancer patients. We have explored the perceptions and preferences of patients, their caregivers (CGs), and health care providers (HCPs) and the current practice and opinions on DNR discussions in a multidisciplinary lung cancer clinic.Materials and Methods: This is a prospective descriptive study with a mixed quantitative and qualitative methodology to capture perceptions of the participants. To obtain a rich description of participant responses to questionnaire items, we employed a ‘think aloud’ process that prompted participants to immediately verbalize their thoughts when responding to questionnaire items. We used content analysis and constant comparison techniques to identify, code and categorize primary themes in the captured data.Results: Ten patients with advanced-stage lung cancer; nine CGs from the lung clinic and ten HCPs from the Thoracic Disease Site Group (DSG) were enrolled in the study. Most patients had only a limited understanding of DNR. Most CGs had a fair to good understanding of DNR. Most HCPs perceived their patients to have understood DNR most of the time. When patients were interviewed, a theme of “anticipated discussion” about DNR was identified. Patients and CGs expressed having faith in the system and responsible physicians as to when to discuss DNR. HCPs embraced a clinician preference-based decision-making approach to engaging in DNR discussions. They desired more resources, more knowledge, more structure and more time to discuss DNR. Most HCPs felt that it would be worth conducting a prospective clinical trial to determine the best time to discuss DNR.Conclusions: This pilot study provides a unique mixed quantitative and qualitative understanding of the perceptions of patients with lung cancer and their CGs and HCPs regarding DNR discussion. Our findings will help further the development of evidence-based guidelines and a broad prospective study that would have important implications for policies and practices around DNR discussions in order to reduce the emotional pain of dying patients, their CGs and HCPs.

Do not attempt cardiopulmonary resuscitation decision-making process: scoping review

“…42 Practice was influenced by observation of other health professionals communicating DNACPR decisions with patients. 49 Most patients and caregivers had already thought about DNACPR in anticipation or preparation of having this discussion with the healthcare provider 32 ; with only 37.5% of them having DNACPR knowledge. DNACPR knowledge had a significant relationship with age and educational level 53 ; 57% of practitioners reported that providing information to the patient was important and 21% stated that this was likely to happen.…”

“…Qualitative & mixed methods a question or uncertainty. 54 Patients' desires related to the seriousness of an imagined or future medical state 32 ; culture and religion are factors that can influence decision making, 17 55 56 76.2% of physicians rated the influence of religion on code status decisions and 82.9% of physicians rated the influence of culture. 29 Religion plays a role in making DNR decisions for 58.3% 31 and the importance of comfort during dying was a priority for 45.3%.…”

The Effect of Practice toward Do-Not-Resuscitate among Taiwanese Nursing Staff Using Path Modeling

“…Higher educational levels among nurses meant having more confidence to deal with patients’ problems in clinical nursing practices [ 45 ]. Prior studies have shown that religious beliefs are a significant factor in forming caregivers’ and health care providers’ viewpoints about DNR decisions [ 46 , 47 ]. This significance is because religious beliefs play an essential role in the lives of many people since spiritual and ethical issues are usually aroused or strengthened as patients near end-of-life, as well as nurses on nursing practice behaviors toward the end-of-life care [ 33 ].…”

Physician workload associated with do-not-resuscitate decision-making in intensive care units: an observational study using Cox proportional hazards analysis

“…Firstly, the physicians’ lack of time to carefully deliberate the appropriateness of writing a DNR order for the patient may relate to this finding. Since most DNR discussions are prompted by physicians, whether they bring the DNR discussion up can significantly influence patients’/surrogates’ DNR decisions [35, 36]. Physicians who were tasked with caring for a higher volume of patients per day might have had less time to carefully deliberate whether or not cardiopulmonary resuscitation is useful or harmful.…”