Residents' end-of-life decision making with adult hospitalized patients: a review of the literature

Hospital do-not-resuscitate orders: why they have failed and how to fix them

Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. 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. 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.e., 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.

Conceptual framework for the study of parental end-of-life decision making in pediatric blood and marrow transplantation

PURPOSE/OBJECTIVES

To describe a conceptual framework that will facilitate research and practice concerning parental end-of-life decision making in pediatric blood and marrow transplantation (BMT).

DATA SOURCES

A review of relevant literature from Ovid, CINAHL, EBSCO, MEDLINE, PsycINFO, and various sociology and theology databases was combined with experiential knowledge.

DATA SYNTHESIS

The method of concept and theory synthesis and derivation as described by Walker and Avant was used in the development of this framework.

CONCLUSIONS

Use of the proposed conceptual framework is expected to provide the organization necessary for thinking, observation, and interpretation of parental end-of-life decision making in pediatric BMT.

IMPLICATIONS FOR NURSING

The ability to describe the process of parental end-of-life decision making in pediatric BMT will help nurses to provide appropriate counseling, education, and support for these children and their families at the end of life. In addition, the process will help nurses to promote the well-being of the children's families after end of life.

Development and use of a decision aid for communication with hospitalized patients about cardiopulmonary resuscitation preference

OBJECTIVE

To develop and evaluate a decision aid related to CPR decision-making for hospitalized patients.

METHODS

The development of the decision aid was guided by published recommendations; physicians, nurses, and a clinical ethicist were involved in the process. In-patients over age 55 with serious illnesses and their family were involved in pre-testing and evaluation.

RESULTS

Twenty-five patients and 11 family members participated. The majority (23/25, 92% of patients, 7/11, 64% of family) reported the information in the decision aid was 'Very' or 'Extremely' helpful in decisions. More than 70% of patients and family considered the aid to be "acceptable." The decision aid did not appear to bias towards or away from preferences for CPR. Participants did not report significant burden with use (median score 2/10; 1=none, 10=extremely upsetting). All patients and 10 family members recommended the aid be available to all patients.

CONCLUSION

The decision aid was felt to be acceptable, feasible, and useful by participants. Future research should evaluate the impact of the decision aid on outcomes including quality of decision-making.

PRACTICE IMPLICATIONS

The decision aid can be used to assist with CPR decision-making with seriously ill hospitalized patients. It is available for use on the CARENET website.

Resident education and management of end-of-life care: the resident's perspective

BACKGROUND

Twenty percent of Americans die in the intensive care unit of our nation's hospitals. Many of those individuals die after life-sustaining therapy has been withdrawn or withheld. Surgeons should be competent in discussing the withholding and withdrawal of life sustaining therapy (WWLST) with their patients. We surveyed surgical residents to learn their perspectives and training experience with discussing end-of-life care and WWLST with patients.

METHODS

We mailed a survey to residents in all accredited surgical residency programs in New England. Nonresponders were contacted by mail at 3 and 6 weeks after the initial mailing.

RESULTS

Nineteen of 20 (95%) programs participated in this study. Three hundred thirty-five residents were surveyed and 141 residents responded (response rate, 42%). Ninety-two percent (n = 129) of respondents had cared for patients where WWLST had occurred, and 74% (n = 104) had initiated a discussion about WWLST themselves. Most (n = 81, 60%) respondents felt competent to discuss WWLST, whereas 14% rarely (n = 13) or never (n = 6) felt comfortable discussing WWLST. Most (n = 119, 85%) respondents believed that they would be adequately trained at the end of their residencies; however, 39% (n = 53) felt they were inadequately trained in this area. Graduates before 2002 were significantly more likely to agree strongly or generally that they would be well trained in managing WWLST when they completed residency (p = 0.006).

CONCLUSION

Almost all surgical residents will have to discuss WWLST with patients and their families, yet a significant number feel inadequately trained to do so. Steps should be taken to ensure that surgical residents can discuss WWLST as part of their core competencies, and this training should be reinforced throughout residency.

Difficulties of residents in training in end-of-life care. A qualitative study

Residents in training are first-line physicians in hospital settings and they are in the process of developing knowledge and mastering clinical skills. They have to confront complex tasks calling upon their personal background, professional identity and relationships with the patients. We conducted a qualitative study investigating the difficulties they perceive in end-of-life care. In all, 24 consecutive residents were presented with a written query asking them to indicate the difficulties they identify in the management of patients hospitalised for end-of-life care. Their responses were submitted to content analysis. Physicians' mean age was 28 +/- 2.2 years, 37% were women, average postgraduate training duration was 2.5 +/- 1.3 years. Content analysis elicited eight categories of difficulties: ability to provide adequate explanations, understand the patients' needs, have sufficient theoretical knowledge, avoid flight, avoid false reassurance, manage provision of time, face one's limits as a physician and be able to help despite everything. Residents' responses showed that they identify the complexity of care in terminally-ill patients early in their training. Their responses pointed to the 'right distance' in-between getting involved and preserving oneself as a dimension of major importance.

Documentation of code status and discussion of goals of care in gravely ill hospitalized patients

BACKGROUND

Timely discussions about goals of care in critically ill patients have been shown to be important.

METHODS

We conducted a retrospective chart review over 2 years (2003-2004) of patients admitted to our medical service who were classified as "expected to die." Charts were evaluated for do-not-resuscitate (DNR) documentation and discussions of goals of care. Detailed chart reviews for demographic information, cause of death, site of death, length of stay, and duration of resuscitation attempt were performed.

RESULTS

Of 497 charts identified, 434 (87.3%) had a DNR on file at the time of death. After exclusion of patients who died in less than 24 hours, 18 no-DNR charts remained. Seven noted a decision to continue aggressive care and 11 had no code status discussion documented. Younger patients and patients with cardiovascular disease were less likely to have a DNR. Resuscitation times were longer in the no-discussion group. All patients who died without a DNR died in the intensive care unit. Seventy-six percent of discussions were done by medicine housestaff.

CONCLUSIONS

Although the overall rate of DNR documentation was high, several trends emerged. Medicine housestaff in the intensive care unit would be a logical group to target for an educational intervention to address these discrepancies.

Changes in internal medicine residents' attitudes about resuscitation after cardiac arrest over a decade

BACKGROUND

Resident physicians' beliefs about cardiopulmonary resuscitation (CPR) may impact their communication with patients about end-of-life care. We sought to understand how these perceptions and experiences have changed in the past decade because both medical education and American society have focused more on this domain.

METHOD

We surveyed 2 internal medicine resident cohorts at a large academic medical center in 1995 and 2005. Residents were asked of their beliefs about survival after CPR, perceived patient understanding, and regret after attempted resuscitation. Residents in 2005 reported more numerical experience with CPR. Current internal medicine residents are more optimistic than the 1995 cohort about survival after an inpatient cardiac arrest. They believe that far fewer patients and families understand resuscitation but report less regret about attempting to resuscitate patients.

CONCLUSIONS

These pilot data reveal potential changes in the attitudes of resident physicians toward CPR. The perceived poor understanding among decision makers calls into question the standard of informed consent. Despite this, residents report less regret leading one to ask what factors may underlie this response.

What it's really like: the complex role of medical students in end-of-life care

BACKGROUND

Medical student end-of-life care training provides insight into the hidden curriculum and physician professional development.

DESCRIPTION

Second-year medical students at a university medical center listen to a panel discussion of 4th-year students and residents describing their end-of-life care experiences during clerkships. This discussion is intended to provide "anticipatory guidance" to 2nd-year students about challenging situations they might encounter on the wards. The purpose of this study was to analyze the content of the panel discussions by 4th-year students and residents to better understand their views of the end-of-life care curriculum.

EVALUATION

We performed a qualitative content analysis of transcripts from 2 years of panel discussions. Participants' comments focused primarily on the complexity of the role of medical students in end-of-life care. Three major themes emerged in the sessions: defining professional identity, conflicting expectations, and limited medical experience.

CONCLUSIONS

The role of medical students in end-of-life care can be complex, confusing, and contradictory. Emotional support and elucidating the hidden curriculum may assist students with the process of physician enculturation and end-of-life care education.

Prevalence of patients with do-not-resuscitate status on acute geriatric wards in Flanders, Belgium

BACKGROUND

Elderly hospitalized patients have low survival rates after cardiopulmonary resuscitation, especially in the long term. This study aims to investigate the prevalence of patients with do-not-resuscitate (DNR) status on acute geriatric wards and the characteristics of the preceding decision-making process.

METHODS

On all 94 geriatric wards in Flanders, Belgium (2002), the geriatrician who performed the bulk of clinical work was asked to fill in a retrospective structured mail questionnaire.

RESULTS

The response rate was 72.3%. A DNR status was attributed to 20.3% of patients. A significant higher prevalence of patients with DNR status was found on wards with a geriatrician who had been active in patient care for 15 years or less and on wards with a DNR policy. Mostly, DNR status was attributed when the patient's condition declined (34.0%) or became critical (29.0%). Geriatricians consulted at least one person in 81.0% of the cases: (head) nurses in 72.2%, next of kin in 61.9%, the patient's general practitioner in 22.6%, and the patient him- or herself in 15.7%. Reasons stated to make a DNR decision were the prognosis (68.1%) and the physical condition of the patient (62.2%). Age was mentioned in only 21.1% of the cases, always in combination with other reasons.

CONCLUSIONS

One fifth of patients on acute geriatric wards in Flanders have DNR status. The decision to attribute DNR status is most often made late in the course of the disease. (Head) nurses and the patient's next of kin are often consulted, the patient and his or her general practitioner rarely.

Understanding and changing attitudes toward withdrawal and withholding of life support in the intensive care unit

A careful examination of our attitudes toward end-of-life care is critical to our understanding of where change is needed to improve patient outcomes. The objectives of our narrative review are 1) to review why the intensive care unit setting presents particular challenges for the delivery of optimal end-of-life care, 2) to outline how four different research methods can provide insights into our understanding of attitudes about withdrawal of life support, and 3) to suggest seven different approaches to changing prevailing attitudes toward withdrawal of life support in the intensive care unit. To better understand attitudes about end-of-life care in general and withdrawal of life support in particular, we reviewed four different sources of data: 1) decision support tools, 2) qualitative research, 3) surveys, and 4) observational studies. Understanding these attitudes offers valuable insights about strategies that may help to improve the care of dying patients and their families. There are several ways to change attitudes; the approaches we reviewed are 1) promoting social change professionally, 2) legitimizing end-of-life research, 3) determining what families of dying patients need, 4) initiating quality improvement locally, 5) evaluating the benefits and harms of new initiatives, 6) modeling quality end-of-life care for future clinicians, and 7) using narratives. Attitudes toward end-of-life care are influenced by many factors and change slowly. Our attitudes have social and personal origins; they are grounded in values that are collective and community based. Different research methods provide insights into attitudes toward death in the intensive care unit and withdrawal of life support in particular. Understanding these attitudes may offer valuable insights about strategies that should help improve the care for dying patients and their families.

End-of-Life Communication in Veterinary Medicine: Delivering Bad News and Euthanasia Decision Making

Given the expectations of clients and the resultant impact of end-of-life conversations on pet owners and the veterinary team, compassionate end-of-life communication is considered to be an ethical obligation, a core clinical skill, and integral to the success of a veterinary team. End-of-life communication is related to significant clinical outcomes, including enduring veterinarian-client-patient relationships and veterinarian and client satisfaction. Effective techniques for end-of-life communication can be taught and are a series of learned skills. The purpose of this article is to present best practices for delivering bad news and euthanasia decision-making discussions. In this article, the SPIKES six-step model (setting, perception, invitation, knowledge, empathize, and summarize) currently employed in medical curricula is utilized to structure end-of-life conversations in veterinary medicine.