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Why They Have Failed and How to Fix Them. ABSTRACTDo- not- resuscitate (DNR) orders have been in use in hospitals nationwide for over 2. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes—to support patient autonomy and to prevent non- beneficial interventions. These failures lead to serious consequences.
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Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today’s use of inpatient DNR orders, i. DNR discussions do not occur frequently enough and occur too late in the course of patients’ illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self- determination and avoiding non- beneficial interventions at the end of life. KEY WORDS: do- not- resuscitate orders, informed consent, end- of- life care.
INTRODUCTIONIn 1. Kouwenhoven and colleagues first introduced closed- chest cardiac massage as an effective means of resuscitating victims of cardiac arrest.
Soon after, the practice known as cardiopulmonary resuscitation (CPR) became a routine emergency procedure performed by any trained provider with a presumption of patient consent to the procedure. Beginning in the 1.
CPR in the US was only 1. This rate has not measurably improved over the last 2.
For patients with certain diagnoses (e. Furthermore, patients who were successfully resuscitated often undergo aggressive treatment in the intensive care unit and suffer complications including rib fractures, permanent neurological deficits, and impaired functional status. Even without physical injury, CPR can lead to psychological harm that lowers survivors’ quality of life. Starting in the mid 1. DNR orders due to concerns that universal CPR could cause more harm than benefit for some patients. These policies served to establish procedures for writing DNR orders, but differed widely across hospitals.
In 1. 98. 3, The President's Commission for the Study of Ethical Problems in Medicine supported DNR order protocols based on three value considerations: self- determination, well- being, and equity. First, the decision for a DNR order should be based foremost on a competent patient’s preference or the previously stated advance directive of a patient who became incompetent. Second, under the principle of well- being, the decision to withhold CPR can be justified when the intervention will not benefit the patient.
The Commission acknowledged that the question of “benefit” is a value- laden one. It involves weighing both the physician’s medical assessment of the chance of success and the patient’s values and goals of care in order to make an adequate determination of benefit. Finally, the Commission believes that resuscitation is a component of care to which all patients should have equitable access and that decisions should not be guided by the concern that the costs incurred could overweigh the potential benefits for some patients. Although intended to promote patient self- determination and prevent non- beneficial interventions, DNR orders often fail to do so. This is because the necessary discussions between physicians and patients or surrogates are often inadequate or absent. In 1. 99. 1, the passage of the Patient Self- Determination Act (PSDA) required all health care institutions to inform patients about their right to complete an advance directive, including their right to refuse life- sustaining interventions such as CPR.
In the years following the PSDA, however, patients were still not significantly involved in decisions regarding resuscitation. The SUPPORT Investigators found that among seriously ill hospitalized patients who wanted CPR to be withheld, half did not have a written DNR order. Furthermore, the patterns of DNR orders suggested that physician- and institution- related biases had a stronger influence on the timing and selection of patients for DNR orders than patient- related factors such as the presence of advance directives. Although problems with DNR orders have been discussed for decades, substantial efforts at reform proved inadequate.
Fortunately, the recent health care reform has created a national impetus to promote safe, high quality care and eliminate costly, ineffective treatments. Now is the opportune time to tackle the problems with DNR orders and push for quality DNR discussions that promote patient- centered care and prevent harmful interventions. In this article, we describe the persistent problems with hospital DNR orders in practice today. We also provide reasons why physicians frequently fail to conduct informed DNR discussions. Finally, we offer a set of strategies to implement on the national, institutional, and physician level that could help to improve conversations regarding resuscitation decisions. PROBLEMS WITH DNR ORDERS IN PRACTICEFour ways in which DNR orders remain problematic today include.
DNR discussions occur too infrequently and patients’ preferences regarding resuscitation are neglected. DNR discussions are delayed until it is too late for the patients to participate in decisions regarding resuscitation.
Physicians do not provide adequate information to allow patients to make informed decisions. Physicians inappropriately extrapolate DNR orders to limit other treatments. DNR discussions: too little and too late. Among hospitalized patients, patient- physician communication about preferences for CPR is inadequate. Many seriously ill patients did not have an opportunity to discuss resuscitation preferences with their physicians, including half of those who wanted resuscitation to be withheld. Physicians were able to successfully predict the resuscitation preferences of patients who wanted a DNR order less than half the time.
Thus, many patients are at risk of being resuscitated against their wishes. When DNR order discussions do occur, they frequently occur too late. A study of 5. 00 patients who suffered from a cardiac arrest showed that 7. DNR orders were incapacitated to make decisions at the time a DNR order was discussed. However, only 1. 1% were impaired at the time of admission.
Only 2. 2% of patients participated in the decision about their DNR order. The majority of DNR orders were written within 2 to 3 days before death. The burden of decision- making was transferred to surrogates, often family members. 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.
DNR discussions fail to satisfy criteria for informed consent. DNR discussions often omit essential information to allow patients or surrogates to make informed decisions. Tulsky and colleagues’ analysis of tape- recorded DNR discussions led by medical residents found that only 4% of residents discussed the chances of survival after CPR, and only in vague, qualitative terms. Discussions about the risks of CPR were rare.
Only two residents mentioned natural death and comfort care measures as alternatives to choosing a resuscitation attempt.