Translating into Practice Cancer Patients’ Views on Do-Not-Resuscitate Decision-Making

Abstract

Do-not-resuscitate (DNR) orders are necessary if resuscitation, the default option in hospitals, should be avoided because a patient is known to be dying and attempted resuscitation would be inappropriate. To avoid inappropriate resuscitation at night, if no DNR order has been recorded, after-hours medical staff are often asked to have a DNR discussion with patients whose condition is deteriorating, but with whom they are unfamiliar. Participants in two qualitative studies of cancer patients’ views on how to present DNR discussions recognized that such patients are at different stages of understanding of their situation and may not be ready for a DNR discussion; therefore, a one-policy-fits-all approach was thought to be inappropriate. To formulate a policy that incorporates the patient’s views, we propose that a standard form which mandates a DNR discussion is replaced by a “blank sheet” with instructions to record the progress of the discussion with the patient, and a medical recommendation for a DNR decision to guide the nursing staff in case of a cardiac arrest. Such an advance care directive would have to honor specifically expressed patient or guardian wishes whilst allowing for flexibility, yet would direct nurses or other staff so that they can avoid inappropriate cardiopulmonary resuscitation of a patient dying of cancer.

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

“…41 Patients themselves favoured having time to discuss their decision with medical staff and family and recognised that this decision could change over time and because of altered circumstances, according to the progression of their disease. 40 Factors that influenced the decision were the wish for a natural death, advanced age and a realistic awareness about the consequences of resuscitation. 57…”

“…38 Physicians have a direct influence on the timing of DNACPR discussions, 33 and the ideal timing of a DNACPR discussion may differ between patients. 40 Timing was influenced by patients' perceived understanding that they are, or will be, dying. 41 However, the attitudes of patients and physicians may differ regarding both the decision-making authority and the timing of the DNACPR decision.…”

“…36 However, conversations need to be held when the patient is healthy, 34 they need to be ongoing so a process occurs over time rather than as a single event, 43 yet standardising the timing and format of DNACPR discussion to fit hospital culture may distress patients. 40…”

Perspectives on the DNR decision process: A survey of nurses and physicians in hematology and oncology

“…According to Duplan and Pirret [ 14 ], the DNR documentation seldom reveals whether the patient and/or family have been informed. When proper documentation is missing, patients can risk receiving unwanted CPR [ 15 , 16 ].…”

“…Other studies have shown that nurses preferred DNR decisions to be made after discussions with patients [ 7 , 20 – 22 ]. Nurses have also expressed the need for clear and well-documented DNR orders and informed patients and relatives, in order to provide good nursing care, such as extra support to the families, helping the patient to a peaceful death and avoiding unwanted CPR [ 7 , 15 ]. Pfeil et al [ 21 ] found that physicians could have a proactive role in which they informed all patients of a DNR decision, or a passive role, in which they waited for the patient to initiate the discussion.…”