The effect of do-not-resuscitate orders on physician decision-making

Palliating Patients Who Have Unresectable Colorectal Cancer: Creating the Right Framework and Salient Symptom Management

The last phases of colorectal malignant illness may be the most challenging and saddening for all involved, but they offer opportunities to become the most rewarding. This transformation of hopelessness to fulfillment requires a willingness by surgeon, patient, and patient's family to trust one another to realistically set goals of care, stick together, and not let the treatment of the disease become a surrogate for treating the suffering that characterizes grave illness.

Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery

BACKGROUND

Emergency surgery patients are older, often critically ill, and at high risk of morbidity and mortality. We studied factors associated with issuance of a do-not-resuscitate (DNR) order and impact on morbidity and mortality in emergency surgery patients.

METHODS

Prospective study of all patients since January 1, 2000 who underwent emergency surgery before admission to the intensive care unit. Data collected were: age, sex, admission diagnosis (case-mix), raw- (AIII) and age-adjusted (aAIII) APACHE III scores, issuance of a DNR order, and morbidity and mortality. Primary outcomes were DNR status and morbidity and mortality. Groups were stratified by age (patients >75 years versus younger) and sex. Statistics were calculated by chi(2) test, analysis of variance, and logistic regression.

RESULTS

In all, 723 emergency surgery patients (gastrointestinal: 35%; traumatic: 20%; neurologic: 17%) met study criteria and had morbidity and mortality of 17.8% (AIII-predicted: 31%). Ninety-two patients (12%) were made DNR, of whom 82.6% died. Women received DNR status more often (16.4% versus 9.5%, p < 0.01) but morbidity and mortality was the same for women and men (18.2% versus 17.5%, p = 0.85). By logistic regression, sex most predicted new DNR status (odds ratio [OR] 2.512, p = 0.005) compared with Multiple Organ Dysfunction score (OR 1.410, p < 0.0001), Age (OR 1.054, p < 0.0001) and aAIII (OR 0.995, 0.355), with goodness of fit of 3.876 (p = 0.868) and Nagelkerke R(2) of 0.511. Percent correct was 88.9, implying good discrimination.

CONCLUSIONS

Female sex and, to a lesser extent, age were associated with issuance of DNR in series of patients who received emergency surgery. The association of DNR with female sex is an unexpected finding and may indicate clinician bias and necessitate the performance of further analysis.

Palliative care: a promising philosophical framework for gastroenterology

Since the 1970s, much has happened to establish palliative care asa health philosophy that will enrich the practice of gastroenterology;conversely, developments in gastroenterology have already improved palliative care. Several recent concepts from the field of gastroenterology such as "the second brain" and "intestinal failure" fit well within the conceptual framework of palliative care. This type of synergy will ultimately encourage the application of this philosophy to a much broader spectrum of patients than those deemed to be at "end of life." This broader spectrum of care can be described as palliative gastroenterology.

An audit of nurses' views on DNR decisions in 1989 and 2003

Guidelines on making do not resuscitate (DNR) decisions have changed in recent years in keeping with changing attitudes and legislation. Decisions should now be discussed with all competent patients, and nursing staff should be involved in the process. The views of nursing staff in 1989 and 2003 were compared, focusing on what factors they thought were important in coming to a DNR decision and any implications it had for other treatment. A patient's wishes, their previous quality of life and the chances of successful resuscitation were rated highly in both studies. Advanced age was rated as important less often in 2003 but was still thought to be an important factor by 61% respondents. In 2003 nurses were significantly more likely to state that active treatment, such as admission to an intensive care unit or surgical intervention, could be appropriate for patients with DNR orders. However, the number of respondents who considered intravenous fluids (18%) or antibiotics (26%) inappropriate for patients not for resuscitation was concerning.

Use of the Physician Orders for Life-Sustaining Treatment Program in Oregon Nursing Facilities: Beyond Resuscitation Status

OBJECTIVES

Program was designed to communicate resident/surrogate treatment preferences in the form of medical orders. To assess statewide nursing facility use of the Physician Orders for Life-Sustaining Treatment (POLST) and to identify the patterns of orders documented on residents' POLST forms.

DESIGN

Telephone survey; on-site POLST form review.

SETTING

Oregon nursing facilities.

PARTICIPANTS

One hundred forty-six nursing facilities in the telephone survey; 356 nursing facility residents aged 65 and older at seven nursing facilities in the POLST form review.

MEASUREMENTS

A telephone survey; onsite POLST form reviews.

RESULTS

In the telephone survey, 71% of facilities reported using the POLST program for at least half of their residents. In the POLST form review, do-not-resuscitate (DNR) orders were present on 88% of POLST forms. On forms indicating DNR, 77% reflected preferences for more than the lowest level of treatment in at least one other category. On POLST forms indicating orders to resuscitate, 47% reflected preferences for less than the highest level of treatment in at least one other category. The oldest old (> or = 85, n=167) were more likely than the young old (65-74, n=48) to have orders to limit resuscitation, medical treatment, and artificial nutrition and hydration.

CONCLUSION

The POLST program is widely used in Oregon nursing facilities. A majority of individuals with DNR orders requested some other form of life-extending treatment, and advanced age was associated with orders to limit treatments.

Knowledge, attitudes, and beliefs about end-of-life care among inner-city African Americans and Latinos

OBJECTIVE

This project explored end-of-life care preferences and barriers among low-income, urban African Americans and Latino/Hispanic Americans (Latinos) to uncover factors that may influence hospice utilization.

METHODS

Focus groups were conducted separately for African Americans (4 groups, n = 26) and Latinos (4 groups, n = 27). Transcripts were coded and analyzed using consensus and triangulation to identify primary themes.

RESULTS

Four preference themes and four barriers were identified. Results were largely similar across the two groups. Both preferred having families provide care for loved ones but expressed desire to reduce caretaker burden. Groups emphasized spirituality as the primary means of coping and valued the holistic well-being of the patient and family. Barriers reported were closely tied to access to care. Participants reported low hospice utilization because of lack of awareness of hospice and the prohibitive cost of health care. Latinos were more likely to report language barriers, while African Americans were more likely to report mistrust of the system.

CONCLUSIONS

African Americans and Latinos in this study were highly receptive to end-of-life care that would provide relief for patients and caregivers and emphasize spirituality and family consensus. Improving awareness of hospice services would likely increase utilization.

Medical decision-making and healthcare disparities: the physician's role

Widespread disparities in US healthcare have been documented with attendant speculation about their causes, including the potential role of the physician as a healthcare decision-maker. However, the current evidence on physician decision-making is inadequate to draw firm conclusions on how it relates to healthcare inequalities. In this article, we review the available evidence on physician decision-making as it relates to healthcare disparities, with an emphasis on its shortcomings, discuss potential sources of bias, including interpersonal factors and physician preferences, and make suggestions for further research in this area.

Advance orders to limit therapy in 67 long-term care facilities in Finland

OBJECTIVE

To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders.

MATERIALS AND METHODS

Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed.

RESULTS

Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders.

CONCLUSIONS

We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.

Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Do-not-resuscitate (DNR) orders are commonly used after severe stroke. We hypothesized that there is significant variability in how these orders are applied after intracerebral hemorrhage and that this influences outcome.

METHODS

From a database of all admissions to nonfederal hospitals in California, discharge abstracts were obtained for all patients with a primary diagnosis of intracerebral hemorrhage who were admitted through the emergency department during 1999 and 2000. Characteristics included whether DNR orders were written within the first 24 hours of hospitalization. Case-mix-adjusted hospital DNR use was calculated for each hospital by comparing the actual number of DNR cases with the number predicted from a multivariable model. Outcome (in-hospital death) was evaluated in a separate multivariable model adjusted for individual and hospital characteristics.

RESULTS

A total of 8233 patients were treated in 234 hospitals. The percentage of patients with DNR orders varied from 0% to 70% across hospitals. Being treated in a hospital that used DNR orders 10% more often than another hospital with a similar case mix increased a patient's odds of dying during hospitalization by 13% (P<0.001). Patients treated in the quartile of hospitals with the highest adjusted DNR use were more likely to die, and this was not just because of individual patient DNR status.

CONCLUSIONS

In-hospital mortality after intracerebral hemorrhage is significantly influenced by the rate at which treating hospitals use DNR orders, even after adjusting for case mix. This is not due solely to individual patient DNR status, but rather some other aspect of overall care.

Effect of Do-Not-Resuscitate Orders on Hospitalization of Nursing Home Residents Evaluated for Lower Respiratory Infections

OBJECTIVES

To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs).

DESIGN

Prospective cohort.

SETTING

Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study.

PARTICIPANTS

NH residents with a LRI (n=1031).

MEASUREMENTS

Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed.

RESULTS

Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97).

CONCLUSION

DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.

Outcomes research in acute renal failure

Acute renal failure (ARF) is associated with morbidity and mortality in excess of 50% in the intensive care unit (ICU) setting. A variety of outcome measures have been described in published reports of ARF, however, the studies often do not distinguish between clinical outcomes and surrogate endpoints. Multiple factors can influence these outcomes, including variations in practice. It is important to be aware of the potential effects of these factors when clinical trials are planned and executed for ARF patients. For any intervention trial, knowledge of the natural history of the disease and process of care informs the design and conduct of the trial. Standardization of a definition for ARF and of the criteria for initiation, frequency, duration, and withdrawal of dialysis support would be of great benefit. This article provides a critical appraisal of outcomes research in ARF and describes an approach for selecting appropriate endpoints for future clinical research in ARF.