Influence of Institutional Culture and Policies on Do-Not-Resuscitate Decision Making at the End of Life

Dzeng, Elizabeth; Colaianni, Alessandra; Roland, Martín; Chander, Geetanjali; Smith, Thomas J.; Kelly, Michael P.; Barclay, Stephen; Levine, David

doi:10.1001/jamainternmed.2015.0295

Cited by 104 publications

(88 citation statements)

References 43 publications

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“…The moral toll exacted upon these physicians is evident in descriptions such as feeling Bviolatedâ nd Btraumatized.T hese findings are consistent with a study by Solomon et al suggesting that trainees Bacted against their conscience in providing care to the terminally ill.^4 The vast majority of respondents in the present study appeared more concerned about providing overly burdensome treatment than undertreatment. Their attitudes may reflect inexperienced doctors' feelings of being trapped by expectations and policies that prioritize patient autonomy, 24 as they have yet to develop the experience or confidence to cope with these ethical conflicts.…”

Section: Discussionmentioning

confidence: 99%

“…18 During the course of these research interviews, moral distress emerged as a major theme amongst trainees. In this paper, we examine how medical physician trainees perceive and respond to ethical challenges arising in the context of treatments at the end of life that they perceive to be futile and how these challenges may contribute to moral distress.…”

Section: Introductionmentioning

confidence: 99%

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Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study

Colaianni²,

et al. 2015

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study

Colaianni²,

et al. 2015

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“…Institutional attitudes towards interventions like do-not-resuscitate (DNR) orders often shape the ethical views of trainees at all levels at such institutions (Dzeng 2015). Understanding clinician attitudes can be the first step toward understanding overall institutional attitudes and how to change the experiential training of medical trainees to account for these attitudes.…”

Section: Discussionmentioning

confidence: 99%

How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making

Bailoor

Valley

Perumalswami

et al. 2018

AJOB Empirical Bioethics

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We conducted an empirical study to explore clinician and lay opinions on the acceptability of physician paternalism. Respondents read a vignette describing a patient with brain hemorrhage facing urgent surgery that would be lifesaving but would result in long-term severe disability. Cases were randomized to show either low or high surrogate distress and certain or uncertain prognosis, with respondents rating the acceptability of not offering brain surgery. Clinicians (N = 169) were more likely than nonclinicians (N = 649) to find the doctor withholding surgery acceptable (30.2% vs. 11.4%, p ≤ 0.001). Among clinicians, the doctor withholding surgery was more acceptable when prognosis was certain to be poor (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.04, 4.01). There was no effect of surrogate distress on clinician ratings. Responses among lay public were more variable. Given the differences in attitudes across clinicians and lay public, there is an ongoing need to engage stakeholders in the process of end-of-life decision making.

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“…However, end-of-life (EOL) care practices are complex and are influenced by multiple factors, including the physicians' personal attitudes, family decisions, economic status, hospital policy, societal culture, and legislation. [2,3] For these reasons, the decision for do-not-resuscitate (DNR) orders and the withholding or withdrawal of life-sustaining management remains both a challenge and an important issue in intensive care units (ICUs).…”

Section: Introductionmentioning

confidence: 99%

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Lim

Lee

et al. 2017

Korean J Crit Care Med

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Background: Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situations. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient distress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU. Methods: We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission. Results: Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001). Conclusions: Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further studies are needed to clarify the guideline for end-of-life care in critically ill patients.

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Influence of Institutional Culture and Policies on Do-Not-Resuscitate Decision Making at the End of Life

Cited by 104 publications

References 43 publications

Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study

Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study

How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making

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