Redefining the emergency physician's role in do-not-resuscitate decision-making

Emergency department DNR order in patients with spontaneous intracerebral hemorrhage

OBJECTIVES

To explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH).

METHODS

Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders.

RESULTS

Among 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different.

CONCLUSIONS

Older and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar.

Evolution of the Literature Identifying Physicians' Roles in Leadership, Clinical Development, and Practice of the Subspecialty of Emergency Medical Services

Purpose: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States.

Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature.

Results: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades.

Conclusions: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.

Resuscitation and senility: a study of patients' opinions

In the context of 'Do-not-resuscitate' (DNR) decisions, there is a lack of information in the UK on the opinions of patients and prospective patients. Written anonymous responses to questionnaires issued to 322 out-patient subjects showed that 97 per cent would opt for cardiopulmonary resuscitation (CPR) in their current state of health. In the hypothetical circumstance of having advanced senile dementia only 10 per cent would definitely want CPR, with 75 per cent preferring not to have CPR. There were no significant correlations between the responses and sex or age. Of 270 patients asked verbally if they found the questions disturbing, none said they did. These findings show that the great majority of patients would not wish CPR if severely senile, and that patients are not disturbed by questions relating to their choice for or against CPR. This should encourage further investigations of patients' opinions on CPR in a broader range of conditions, and greater use of DNR orders.