Increasing use of DNR orders in the elderly worldwide: whose choice is it?

Abstract

Most elderly patients die with an order in place that they not be given cardiopulmonary resuscitation (DNR order). Surveys have shown that many elderly in different parts of the world want to be resuscitated, but may lack knowledge about the specifics of cardiopulmonary resuscitation (CPR). Data from countries other than the US is limited, but differences in physician and patient opinions by nationality regarding CPR do exist. Physicians' own preferences for CPR may predominate in the DNR decision making process for their patients, and many physicians may not want the participation of the elderly or believe that it is necessary. More complete and earlier discussions of a wider range of options of care for patients at the end of life have been advocated. The process ought to include education for patients about the process and efficacy of CPR, and for physicians on how to consider the values and levels of knowledge of their patients, whose preferences may differ from their own.T he use of do-not-resuscitate (DNR) orders, which preclude the use of cardiopulmonary resuscitation (CPR) has been increasing in all individuals, including the elderly, over the past several decades. 1-11 Several surveys suggest that the majority of hospitalised and institutionalised patients in the United States, and many abroad, die with a DNR order in place, 7 which was not true twenty years ago. The US Patient Self-Determination Act of 1991, which requires patients be informed of their rights to issue advance directives and be involved in medical decision making, appears to have increased the use of DNR orders. 12 While the use of the DNR order has been less systematically studied in other countries, many patients in the developed and developing world also die with a DNR order in place . [12][13][14][15][16][17][18][19][20][21] The elderly are more likely than the young to be the recipients of DNR orders. Most, 6 10 13-15 22-29 but not all 1 surveys indicate older patients, regardless of prognosis, are more frequently given a DNR order than a young patients. It remains an open question, however, whether more elderly people die with a DNR order in place because they are actually choosing to do so. Many studies show that most patients are never asked by a doctor if they wish to be resuscitated, despite a desire to express their wishes. Data from the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) project, canvassing almost 1000 seriously ill elderly patients, noted that only approximately one quarter had ever discussed CPR with a physician. 30

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

“…Several studies suggested that patients would decline quantity of life in the absence of quality [1]. A common misunderstanding patients and families have is that CPR would keep patients alive and living as they were before the code.…”

“…European studies had revealed that physicians' and patients' religion could cause significant differences in the use of end-of-life therapies with values and practices differing from country to country [13]. Differences in training and personal religious beliefs have been suggested as responsible for variations in attitudes [1].…”

“…Several surveys suggested that the majority of hospitalized patients died with a DNR (do not resuscitate) order in place [1]. In the mid-1970s, hospitals began to implement policies on DNR orders.…”

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

“…28 This is problematic because family members are frequently unfamiliar with the procedures involved in CPR, lack accurate information about patients' prognoses, and routinely overestimate patients' preferences for CPR and other life-sustaining treatments. 31,32 DNR discussions fail to satisfy criteria for informed consent. DNR discussions often omit essential information to allow patients or surrogates to make informed decisions.…”

Do not attempt resuscitation order in Japan

“…However, even if a patient has a poor prognosis, it does not always mean that he/she does not wish to be resuscitated or receive aggressive treatment. As the final decision on DNAR orders will differ according to the attitude of the individual patient,10, 11, 12, 13 it is essential to confirm each and every patient's intentions wherever possible. Apart from these diseases and background factors, patients with sequelae of cerebrovascular disease or dementia or patients in a persistent vegetative state may lack decision‐making capability.…”