Patient reluctance to accept Do Not Resuscitate order: impact on clinical care

Abstract

Background: A Do Not Resuscitate (DNR) order should only impede the performance of cardiopulmonary resuscitation in case of cardiac or respiratory arrest; it should not interfere with any other treatment decisions. Aims: To study the impact of DNR order placement on daily clinical care of patients. Methods: This was a retrospective cohort study of 72 patients in a tertiary care centre in Saudi Arabia. Daily clinical care measures were collected for 2 weeks prior and 2 weeks after DNR order placement and included vital signs, nursing care, comfort measures, documentation, visits by senior and junior physicians, and tests completed. Results: Malignancy was the most common diagnostic category (43.1%). There was a significant reduction in vital signs documentation, tests completed, documentation, and visits by physicians after DNR orders, with no change in nursing care and comfort measures. No differences were seen for place of DNR order (intensive care unit vs medical ward), category of disease, or sex, but there were differences for documentation (more in females) and vital signs (more in males). More vital signs were documented and more tests were done in patients who survived compared to those who died. Regression analysis showed that the frequency of post-DNR order vital signs measurements and investigations done was not related to sex, age, diagnosis, time from admission to DNR order, or location of patients. Time to death was only related to sex and post-DNR order summary documentation. Conclusions: Placement of DNR orders significantly reduced vital signs measurements, investigations done, documentation and visits by physicians but not nursing care and comfort measures.

Current state of ethical challenges reported in Saudi Arabia: a systematic review & bibliometric analysis from 2010 to 2021

“…Still, it required deeper knowledge to learn whether there is a clear local or national DNR policy. Those who knew about the policy did not read in detail [ 60 – 63 , 67 , 68 , 70 ]. The most common limitation of essential discussions about DNR was a lack of patient understanding, educational level, cultural background of patients, and a lack of DNR policy knowledge by medical staff [ 60 – 64 ].…”

“…Studies in which patients were included as a target population reported a lack of knowledge of the medical conditions for DNR practice [ 62 , 65 , 66 , 68 , 69 ]. Patients expressed a will to participate in discussions with doctors on planning end-of-life care and making their own decisions.…”

“…Patients expressed a will to participate in discussions with doctors on planning end-of-life care and making their own decisions. Patients with higher levels of education, medical background, and knowledge of DNR were more likely to agree with DNR practice [ 62 , 65 , 66 , 68 , 69 ].…”

“…The most common limitation of essential discussions about DNR was a lack of patient understanding, educational level, cultural background of patients, and a lack of DNR policy knowledge by medical staff [60][61][62][63][64]. Most health care representatives wanted to learn more about patients' rights regarding end-of-life care and the use of the DNR order, as this would support the treatment plan for terminally ill patients [60,62,67,68,71].…”

Do Not Resuscitate (DNR) Orders from an Islamic Perspective

“…However, some patients wish not to be resuscitated. The literature has studied this order, the Do-Not-Resuscitate (DNR), for patients who suffer from severe burns, 3 cardiopulmonary insufficiency, 4 cancer, 5 dementia, 6 and for the elderly. 7 As of 2008, CPR has been implemented under the code blue procedure, and the right of DNR has been contested.…”