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Mertens V, Cottignie C, van de Wiel M, Vandewoude M, Perkisas S, Roelant E, Moorkens G, Hans G. Comprehensive geriatric assessment as an essential tool to register or update DNR codes in a tertiary care hospital. Eur Geriatr Med 2024; 15:295-303. [PMID: 38277096 DOI: 10.1007/s41999-023-00925-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE To investigate the prevalence of Do not Resuscitate (DNR) code registration in patients with a geriatric profile admitted to Antwerp University Hospital, a tertiary care hospital in Flanders, Belgium, and the impact of comprehensive geriatric assessment (CGA) on DNR code registration. PATIENTS AND METHODS Retrospective analysis of a population of 543 geriatric patients (mean age 82.4 ± 5.19 years, 46.4% males) admitted to Antwerp University Hospital from 2018 to 2020 who underwent a CGA during admission. An association between DNR code registration status before and at hospital admission and age, gender, ethnicity, type of residence, clinical frailty score (CFS), cognitive and oncological status, hospital ward and stay on intensive care was studied. Admissions before and during the first wave of the pandemic were compared. RESULTS At the time of hospital admission, a DNR code had been registered for 66.3% (360/543) of patients. Patients with a DNR code at hospital admission were older (82.7 ± 5.5 vs. 81.7 ± 4.6 years, p = 0.031), more frail (CFS 5.11 ± 1.63 vs. 4.70 ± 1.61, p = 0.006) and less likely to be admitted to intensive care. During the hospital stay, the proportion of patients with a DNR code increased to 77% before and to 85.3% after CGA (p < 0.0001). Patients were consulted about and agreed with the registered DNR code in 55.8% and 52.1% of cases, respectively. The proportion of patients with DNR codes at the time of admission or registered after CGA did not differ significantly before and after the start of the COVID-19 pandemic. CONCLUSION After CGA, a significant increase in DNR registration was observed in hospitalized patients with a geriatric profile.
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Affiliation(s)
- Veerle Mertens
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium.
| | - Charlotte Cottignie
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium
| | - Mick van de Wiel
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium
| | - Maurits Vandewoude
- Department of Geriatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium
| | | | - Ella Roelant
- Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Greta Moorkens
- Department of Internal Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Antwerp, Belgium
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Çuvalci B, Akbal Y, Hintistan S. Turkish Muslim Physicians' and Nurses' Views About the Do Not Resuscitate Order: A Cross-Sectional Two Center Study. OMEGA-JOURNAL OF DEATH AND DYING 2023; 88:690-708. [PMID: 34590886 DOI: 10.1177/00302228211049879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aims to determine Turkish Muslim physicians' and nurses' views about the Do Not Resuscitate order and the factors influencing these views. This was a cross-sectional, descriptive study. The sample consisted of 327 health workers including 77 physicians and 250 nurses employed in internal and surgical clinics, intensive care units and emergency services of two different university hospitals located in the northeast of Turkey. 90.9% of Muslim Turkish physicians and 74.4% of nurses request the Do Not Resuscitate order to be legally implemented. The factors predicting 40.0% of Muslim Turkish physicians and nurses requesting the legal implementation of the Do Not Resuscitate order were determined as working at institution 1; requesting implemented before emergencies occur, in emergencies and in both cases; considering informing the patient and their surrogates about as a patient's right; and requesting to be a surrogate for one relatives.
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Affiliation(s)
- Burcu Çuvalci
- Health and Care Services/Elderly Care, Recep Tayyip Erdoğan University Health Services Vocational High School, Rize, Turkey
| | - Yağmur Akbal
- Health Services Vocational High School, Medical Services and Techniques/Anesthesia, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Sevilay Hintistan
- Internal Disease Nursing, Faculty of Health Sciences, Karadeniz Technical University, Trabzon, Turkey
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Rakhshan M, Joolaee S, Mousazadeh N, Hakimi H, Bagherian S. Causes of futile care from the perspective of intensive care unit nurses (I.C.U): qualitative content analysis. BMC Nurs 2022; 21:225. [PMID: 35953793 PMCID: PMC9371949 DOI: 10.1186/s12912-022-01004-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background Medical care that has therapeutic effects without significant benefits for the patient is called futile care. Intensive Care Units are the most important units in which nurses provide futile care. This study aimed to explain the causes of futile care from the perspective of nurses working in Intensive Care Units are. Method The study was conducted using a qualitative approach. Qualitative content analysis was used to analyze the data. Study participants were 17 nurses who were working in the Intensive Care Units are of hospitals in the north of Iran. They were recruited through a purposeful sampling method. Data was gathered using in-depth, semi-structured interviews from March to June 2021. Recruitment was continued until data saturation was reached. Results Two main themes, four categories, and thirteen subcategories emerged from the data analysis. The main themes were principlism and caring swamp. The categories were moral foundation, professionalism, compulsory care, and patient’s characteristics. Conclusion In general, futile care has challenged nursing staff with complex conflicts. By identifying some of these conflicts, nurses will be able to control such situations and plan for better management strategies. Also, using the findings of this study, nursing managers can adopt supportive strategies to reduce the amount of futile care and thus solve the specific problems of nurses in intensive care units such as burnout, moral stress, and intention to leave.
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Affiliation(s)
- Mahnaz Rakhshan
- Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soodabeh Joolaee
- Department of Evaluation & Research Service, Fraser health authority, Surrey, Canada.,Research Center of Health Evaluation & Outcome Science, UBS, Vancouver, Canada.,Nursing Care Research Center, Iran University of Medical Science, Tehran, Iran
| | - Noushin Mousazadeh
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Science, Sari, Iran.
| | - Hamideh Hakimi
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Samaneh Bagherian
- Department of Operating Room, School of Paramedical Sciences, Birjand University of Medical Sciences, Birjand, Iran
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van der Werff HFL, Michelet TH, Fredheim OM, Steine S. "Do not resuscitate" order and end-of-life treatment in a cohort of deceased in a Norwegian University Hospital. Acta Anaesthesiol Scand 2022; 66:1009-1015. [PMID: 35699950 PMCID: PMC9544634 DOI: 10.1111/aas.14104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/31/2022] [Accepted: 05/11/2022] [Indexed: 11/27/2022]
Abstract
Background A “Do not resuscitate” (DNR) order implies that cardiopulmonary resuscitation will not be started. Absent or delayed DNR orders in advanced chronic disease may indicate suboptimal communication about disease stage, prognosis, and treatment goals. The study objective was to determine clinical practice and patient involvement regarding DNR and the prevalence of life‐prolonging treatment in the last week of life. Methods A cross‐sectional observational study was made of a cohort of 315 deceased from a large general hospital in Norway. Data on DNR and other treatment limitations, life‐prolonging treatment in the last week of life, and cause of death were obtained from medical records. Results A DNR order was documented for 287 (91%) patients. Almost half the DNR orders, 142 (49%), were made during the last 7 days of life. The main causes of death were cancer (31%), infectious diseases (31%), and cardiovascular diseases (19%). The most frequent life‐prolonging treatments during the last week of life were intravenous fluids in 221 patients (70%) and antibiotics in 198 (63%). During the last week of life, 103 (36%) patients received ICU treatment. Death by cancer (odds ratio 2.5, 95% confidence interval 1.24–5.65) and DNR decision made by a palliative care physician (odds ratio 3.4, 95% CI 1.21–3.88) were predictors of not receiving life‐prolonging treatment. Conclusion The findings of a high prevalence of life‐prolonging treatment in the last week of life and DNR orders being made close to the time of death indicate that decisions about limiting life‐prolonging treatment are often postponed until the patient's death is imminent.
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Affiliation(s)
| | - Torstein H Michelet
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Olav M Fredheim
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Advisory Unit on Complex Symptom Disorders, St. Olavs Hospital, Trondheim, Norway
| | - Siri Steine
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
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Dabar G, Akl IB, Sader M. Physicians' approach to end of life care: comparison of two tertiary care university hospitals in Lebanon. BMC MEDICAL EDUCATION 2021; 21:592. [PMID: 34823513 PMCID: PMC8620620 DOI: 10.1186/s12909-021-03022-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 09/14/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The care of terminally ill patients is fraught with ethical and medical dilemmas carried by healthcare professionals. The present study aims to explore the approaches of Lebanese attending physicians towards palliative care, end of life (EOL) care, and patient management in two tertiary care university hospitals with distinct medical culture. METHODS Four hundred attending physicians from the American University of Beirut Medical Center (AUBMC) and Hotel Dieu de France (HDF) were recruited. Participants were Medical Doctors in direct contact with adult patients that could be subject to EOL situations providing relevant demographic, educational, religious as well as personal, medical or patient-centric data. RESULTS The majority of physicians in both establishments were previously exposed to life-limiting decisions but remains uncomfortable with the decision to stop or limit resuscitation. However, physicians with an American training (AUBMC) were significantly more likely to exhibit readiness to initiate and discuss DNR with patients (p<0.0001). While the paternalistic medicinal approach was prevalent in both groups, physicians with a European training (HDF) more often excluded patient involvement based on family preference (p<0.0001) or to spare them from a traumatic situation (p=0.003). The majority of respondents reported that previous directives from the patient were fundamental to life-limiting decisions. However, the influence of patient and medical factors (e.g. culture, religion, life expectancy, age, socioeconomic status) was evidenced in the HDF group. CONCLUSION Early physician-initiated EOL discussions remain challenged in Lebanon. Paternalistic attitudes limit shared decision making and are most evident in European-trained physicians. Establishing a sound and effective framework providing legal, ethical and religious guidance is thus needed in Lebanon.
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Affiliation(s)
- George Dabar
- Pulmonary and Critical Care Division, Hotel Dieu de France Hospital, Saint Joseph University, Boulevard Alfred Naccache Achrafieh, PO Box 166830, Beirut, Lebanon
| | - Imad Bou Akl
- Pulmonary and Critical Care Division, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mirella Sader
- Anesthesia and Critical Care Division, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
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Jiang T, Ma Y, Zheng J, Wang C, Cheng K, Li C, Xu F, Chen Y. Prevalence and related factors of do-not-resuscitate orders among in-hospital cardiac arrest patients. Heart Lung 2021; 51:9-13. [PMID: 34731700 DOI: 10.1016/j.hrtlng.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Studies concerning do-not-resuscitate (DNR) orders in mainland China are rather scarce. We explored the prevalence and related factors of DNR orders among in-hospital cardiac arrest (IHCA) patients at a general tertiary hospital in mainland China. MATERIALS AND METHODS We identified all IHCA patients hospital-wide between July 2019 and September 2020. Data regarding DNR status were collected from medical records. We investigated the frequency of DNR orders and explored the determinant factors of DNR establishment using logistic regression. RESULTS A total of 1154 IHCA patients were included, 535 (46.4%) of whom established DNR orders. The following variables were independently associated with a higher DNR rate: female (OR 1.491; 95% CI 1.130-1.965), older age (OR 1.016; 95% CI 1.008-1.024), being a local resident (OR 1.790; 95% CI 1.344-2.383), pulmonary infection (OR 1.398; 95% CI 1052-1.859), respiratory insufficiency (OR 1.356; 95% CI 1.009-1.823), shock (OR 1.735; 95% CI 1.301-2.313), acute stroke (OR 1.821; 95% CI 1.235-2.686),neurological dysfunction (OR 1.527; 95% CI 1.149-2.028) and cancer (OR 3.316; 95% CI 2.461-4.468). Counterintuitively, patients with new-onset coronary artery disease (OR 0.592; 95% CI 0.419-0.837) were less likely to create DNR orders. CONCLUSION In mainland China, the DNR order signing rate is low, and the establishment of a DNR order is associated with demographics and comorbidity characteristics.
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Affiliation(s)
- Tangxing Jiang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Yanyan Ma
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chunyi Wang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Kai Cheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chuanbao Li
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
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Raoofi N, Raoofi S, Jalali R, Abdi A, Salari N. The worldwide investigating nurses' attitudes towards do-not-resuscitate order: a review. PHILOSOPHY ETHICS AND HUMANITIES IN MEDICINE 2021; 16:5. [PMID: 34488819 PMCID: PMC8422718 DOI: 10.1186/s13010-021-00103-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/15/2021] [Indexed: 11/13/2022]
Abstract
Background The acceptance or practical application of the do-not-resuscitate order is substantially dependent on internal or personal factors; in a way that decision-making about this issue can be specific to each person. Moreover, most nurses feel morally and emotionally stressed and confused during the process decision-making regarding DNR order. Therefore, the purpose of the present study was to evaluate nurses’ attitudes towards DNR order in a systematic review. Methods This critical survey was conducted using a systematic review protocol. To this end, the most relevant articles published in domestic and foreign databases with no time limits until October 2018 were searched. The inclusion and exclusion criteria were articles on DNR order, studies about nurses’ attitudes, descriptive and analytical research papers, as well as those with download links and full texts. The given articles were also assessed in terms of their quality and their main results were extracted. Results Of the total number of 1663 articles searched in the process of systematic review to investigate nurses’ attitudes towards DNR order, 88 articles were included in the full-text review step and finally 10 articles, meeting the inclusion criteria, were found. Assessing the quality of articles included in this review showed that 8 articles, in general, were of good quality and 2 studies were characterized with moderate quality. The main factors associated with nurses’ attitudes towards DNR order were grouped into three categories of (1) nurses’ attitudes towards DNR order, (2) guidelines for DNR order, and (3) decision-making by patients and their families about DNR order. In most of the studies examined, nurses’ attitudes towards DNR order were reported positive. Conclusion It seemed that nurses were willing to get involved in DNR order and each hospital was recommended to develop a written DNR policy directing individuals and avoiding their confusion in this respect.
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Affiliation(s)
- Neda Raoofi
- Department Nursing, Nursing and Midwifery Faculty, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Samira Raoofi
- Health Care Management, Iran University of Medical Sciences, Tehran, Iran
| | - Rostam Jalali
- Department Nursing, Nursing and Midwifery Faculty, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Alireza Abdi
- Faculty of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nader Salari
- Faculty of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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AbuYahya O, Abuhammad S, Hamoudi B, Reuben R, Yaqub M. The do not resuscitate order (DNR) from the perspective of oncology nurses: A study in Saudi Arabia. Int J Clin Pract 2021; 75:e14331. [PMID: 33960067 DOI: 10.1111/ijcp.14331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Issues related to life and death are largely influenced by the culture and religious beliefs of a society. This research aimed to survey a sample of oncology nurses in Saudi Arabia about their attitude towards the do not resuscitate order (DNR). METHOD A cross-sectional design was employed. A survey was sent to 190 nurses in the Comprehensive Cancer Center (CCC) in King Fahad Medical City (KFMC). A total of 157 nurses with a diploma or higher degree agreed to participate in the study. RESULTS Many nurses showed a neutral attitude regarding DNR to cancer patients and/or their families 2.4 ± 0.4. Moreover, the results of the multiple logistic regression tests revealed that all the listed factors are not associated with the attitude towards DNR orders (P > .05). CONCLUSION It is generally believed that nurses the faith and background of nurses from Muslim countries has a profound influence on their attitude towards DNR. However, this was not the picture that was revealed by the results of this study. In this study, all the nurses made it clear that they wanted to know about the autonomy of patients in respect of DNR orders. IMPLICATION TO CLINICAL PRACTICE It is necessary to develop programmes that address the DNR order and respect patient autonomy and rights. Moreover, hospital policies that address the issues of DNR order are required for all end-of-life care.
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Affiliation(s)
- Omar AbuYahya
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Sawsan Abuhammad
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Bara Hamoudi
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Ranjni Reuben
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Muawiyah Yaqub
- Comprehensive Cancer Center (CCC), King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
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Cammarota G, Esposito T, Azzolina D, Cosentini R, Menzella F, Aliberti S, Coppadoro A, Bellani G, Foti G, Grasselli G, Cecconi M, Pesenti A, Vitacca M, Lawton T, Ranieri VM, Di Domenico SL, Resta O, Gidaro A, Potalivo A, Nardi G, Brusasco C, Tesoro S, Navalesi P, Vaschetto R, De Robertis E. Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis. Crit Care 2021; 25:268. [PMID: 34330320 PMCID: PMC8324455 DOI: 10.1186/s13054-021-03697-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/21/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.
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Affiliation(s)
- Gianmaria Cammarota
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy.
| | - Teresa Esposito
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Danila Azzolina
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | | | - Francesco Menzella
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Di Reggio Emilia, Reggio Emilia, Italy
| | - Stefano Aliberti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Giacomo Bellani
- ASST Monza, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- ASST Monza, San Gerardo Hospital, Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Vitacca
- Respiratory Rehabilitation Unit Lumezzane, ICS Maugeri IRCCS, Brescia, Italy
| | - Tom Lawton
- Department of Anesthesia and Critical Care, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - V Marco Ranieri
- Anesthesia and Intensive Care Medicine, Policlinico Di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | - Onofrio Resta
- Cardiothoracic Department, Respiratory Unit, University Hospital, Bari, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Ospedale Luigi Sacco, Milan, Italy
| | - Antonella Potalivo
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Della Romagna, Rimini, Italy
| | - Giuseppe Nardi
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Della Romagna, Rimini, Italy
| | - Claudia Brusasco
- Anesthesia and Intensive Care Unit, E.O. Ospedali Galliera, Genoa, Italy
| | - Simonetta Tesoro
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy
| | - Paolo Navalesi
- Department of Medicine-DIMED, Università Di Padova, Padua, Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, University of Perugia, Piazza Università 1, 06123, Perugia, Italy
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10
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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11
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Piscator E, Djärv T, Rakovic K, Boström E, Forsberg S, Holzmann MJ, Herlitz J, Göransson K. Low adherence to legislation regarding Do-Not-Attempt-Cardiopulmonary-Resuscitation orders in a Swedish University Hospital. Resusc Plus 2021; 6:100128. [PMID: 34223385 PMCID: PMC8244392 DOI: 10.1016/j.resplu.2021.100128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background The ethical principles of resuscitation have been incorporated into Swedish legislation so that a decision to not attempt cardiopulmonary resuscitation (DNACPR) entails (1) consultation with patient or relatives if consultation with patient was not possible and documentation of their attitudes; (2) consultation with other licensed caregivers; (3) documentation of the grounds for the DNACPR. Our aim was to evaluate adherence to this legislation, explore the grounds for the decision and the attitudes of patients and relatives towards DNACPR orders. Methods We included DNACPR forms issued after admission through the emergency department at Karolinska University Hospital between 1st January and 31st October, 2015. Quantitative analysis evaluated adherence to legislation and qualitative analysis of a random sample of 20% evaluated the grounds for the decision and the attitudes. Results The cohort consisted of 3583 DNACPR forms. In 40% of these it was impossible to consult the patient, and relatives were consulted in 46% of these cases. For competent patients, consultation occurred in 28% and the most common attitude was to wish to refrain from resuscitation. Relatives were consulted in 26% and they mainly agreed with the decision. Grounds for the DNAR decision was most commonly severe chronic comorbidity, malignancy or multimorbidity with or without an acute condition. All requirements of the legislation were fulfilled in 10% of the cases. Conclusion In 90% of the cases physicians failed to fulfil all requirements in the Swedish legislation regarding DNAR orders. The decision was mostly based on chronic, severe comorbidity or multimorbidity.
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Affiliation(s)
- Eva Piscator
- Department of Medicine Solna, Karolinska Institutet and Department of Emergency Medicine, Capio S:t Görans Hospital, Stockholm, Sweden
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet and Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Rakovic
- Function of Perioperative Medicine and Intensive Care Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Emil Boström
- Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Sune Forsberg
- Center for Resuscitation Science, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet and Department of Anaesthesiology and Intensive Care, Norrtälje Hospital, Norrtälje, Sweden
| | - Martin J Holzmann
- Department of Medicine Solna, Karolinska Institutet Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Herlitz
- Center of Prehospital Research, Faculty of Caring Science, Work-life and Welfare, University of Borås and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Katarina Göransson
- Department of Medicine Solna, Karolinska Institutet Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
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12
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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13
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Gül Ş, Bağcivan G, Aksu M. Nurses' Opinions on Do-Not-Resuscitate Orders. OMEGA-JOURNAL OF DEATH AND DYING 2020; 86:271-283. [PMID: 33095667 DOI: 10.1177/0030222820969317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to determine nurses' opinions on Do Not Resuscitate (DNR) orders. This is a descriptive study. A total of 1250 nurses participated in this study. The mean age of participants was 34.5 ± 7.7 years; 92.6% were women; 56.4% had bachelor's degrees, and 28.8% were intensive care, oncology, or palliative care nurses. Most participants (94.3%) agreed that healthcare professionals involved in DNR decision-making processes should have ethical competence, while they were mostly undecided (43%) about the statement whether or not DNR should be legal. More than half the participants (60.2%) disagreed with the idea that DNR implementation causes an ethical dilemma. Participants' opinions on DNR decisions significantly differed according to the number of years of employment and unit of duty. The results showed that most of the nurses had positive attitudes towards DNR orders despite it being illegal. Future studies are needed to better understand family members' and decision makers' perceptions of DNR orders for patients.
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Affiliation(s)
- Şenay Gül
- Faculty of Nursing, Hacettepe University, Ankara, Turkey
| | | | - Miray Aksu
- Gulhane Training and Research Hospital, Ankara, Turkey
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14
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Cui P, Ping Z, Wang P, Bie W, Yeh CH, Gao X, Chen Y, Dong S, Chen C. Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study. Support Care Cancer 2020; 29:1893-1902. [PMID: 32803724 DOI: 10.1007/s00520-020-05672-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients. METHODS This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system. RESULTS In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders. CONCLUSIONS Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.
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Affiliation(s)
- Panpan Cui
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China.,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhiguang Ping
- College of Public Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Panpan Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wenqian Bie
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Chao Hsing Yeh
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, USA
| | - Xinyi Gao
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yiyang Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shiqi Dong
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changying Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China. .,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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15
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Madadin M, Alsaffar GM, AlEssa SM, Khan A, Badghaish DA, Algarni SM, Menezes RG. Clinicians' Attitudes Towards Do-Not-Resuscitate Directives in a Teaching Hospital in Saudi Arabia. Cureus 2019; 11:e6510. [PMID: 31903316 PMCID: PMC6937465 DOI: 10.7759/cureus.6510] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The Do-Not-Resuscitate (DNR) directive has provided a major leap in end-of-life care. To demonstrate the factors influencing physicians' DNR decisions in King Fahd University Hospital in the Eastern Province of Saudi Arabia, 42 physicians from the medical and surgical departments of the same center were requested to participate in a cross-sectional survey. Thirty-six questionnaires were completed and returned from a total of 42 distributed among physicians, making a response rate of 85.7%. Certain diagnostic categories increase the likelihood of issuing a DNR order for a patient. Neurological (58.3%) and cardiovascular (41.7%) diseases were the highest response among other diseases in influencing physicians' decisions. In addition, other factors like lack of comorbidities (55.5%), age (52.7%), and previous intensive care unit (ICU) admissions and resuscitation (44.4%) showed an effect on the directive decisions of DNR among investigated physicians. However, weak palliative care in the hospital (11.1%), religious beliefs (5.5%), and gender (2.7%) were the least associated factors affecting physicians' DNR decisions. This study addresses the influencing factors of DNR orders issuance among King Fahd Hospital of the University physicians. Physicians noted that cultural standards and religious beliefs do play a role in their decision-making but had less of an effect as compared to other clinical data such as comorbidities, age, and previous ICU admissions.
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Affiliation(s)
- Mohammed Madadin
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Gada M Alsaffar
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Sara M AlEssa
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Afnan Khan
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Dania A Badghaish
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Shahad M Algarni
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Ritesh G Menezes
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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16
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Chen CH, Cheng YH, Chen FJ, Huang EY, Liu PM, Kung CT, Su CH, Chen SH, Chien PC, Hsieh CH. Association Between the Communication Skills of Physicians and the Signing of Do-Not-Resuscitate Consent for Terminally Ill Patients in Emergency Rooms (Cross-Sectional Study). Risk Manag Healthc Policy 2019; 12:307-315. [PMID: 31849547 PMCID: PMC6911809 DOI: 10.2147/rmhp.s232983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/21/2019] [Indexed: 12/01/2022] Open
Abstract
Background The signing of do-not-resuscitate (DNR) consent is mandatory in providing a palliative approach in the end-of-life care for the terminally ill patients and requires an effective communication between the physician and the patients or their family members. This study aimed to investigate the association between the communication skills of physicians who participated in the SHARE (supportive environment, how to deliver the bad news, additional information, reassurance, and emotional support) model course on the patient notification and the signing of do-not-resuscitate (DNR) consent by the terminally ill patients at emergency rooms. Methods Between May 1, 2017 and April 30, 2018, a total of 109 terminally ill patients were enrolled in this study, of which 70 had signed a DNR and 39 had not. Data regarding the patients’ medical records, a questionnaire survey completed by family members, and patient observation forms were used for the assessment of physicians’ communication skills during patient notification. The observation form was designed based on the SHARE model. A multivariate logistic regression model was applied to identify the independent significant factors of the patient and family member variables as well as the four main components of the observation form. Results The results revealed that knowing how to convey bad news and providing reassurance and emotional support were significantly correlated with a higher rate of signing DNR consent. Additionally, physician-initiated discussion with family members and a predicted limited life expectancy were negative independent significant factors for signing DNR consent. Conclusion This study revealed that good communication skills help to increase the signing of DNR consent. The learning of such skills from attendance of the SHARE model course is encouraged for the physicians in the palliative care of terminally ill patients in an emergency room.
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Affiliation(s)
- Chih-Hung Chen
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung 802, Taiwan
| | - Ya-Hui Cheng
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, 736, Taiwan
| | - Fen-Ju Chen
- Department of Healthcare Administration, I-Shou University Medical Campus, Kaohsiung 824, Taiwan
| | - Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Po-Ming Liu
- Department of Emergency Medicine, Kaohsiung 802, Taiwan
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Chao-Hui Su
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Shu-Hwa Chen
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,School of Nursing, Fooyin University, Kaohsiung 831, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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17
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ÖZLÜ T, PEHLİVANLAR KÜÇÜK* M, KAYA A, YARAR E, KIRAKLI C, ŞENGÖREN DİKİŞ Ö, KEFELİ ÇELİK H, ÖZKAN S, BEKTAŞ AKSOY H, KÜÇÜK AO. Can we predict patients that will not benefit from invasive mechanical ventilation? A novel scoring system in intensive care: the IMV Mortality Prediction Score (IMPRES). Turk J Med Sci 2019; 49:1662-1673. [PMID: 31655511 PMCID: PMC7518657 DOI: 10.3906/sag-1904-96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/28/2019] [Indexed: 01/31/2023] Open
Abstract
Background/aim The present study aimed to define the clinical and laboratory criteria for predicting patients that will not benefit from invasive mechanical ventilation (IMV) treatment and determine the prediction of mortality and prognosis of these critical ill patients. Materials and methods The study was designed as an observational, multicenter, prospective, and cross-sectional clinical study. It was conducted by 75 researchers at 41 centers in intensive care units (ICUs) located in various geographical areas of Turkey. It included a total of 1463 ICU patients who were receiving invasive mechanical ventilation (IMV) treatment. A total of 158 parameters were examined via logistic regression analysis to identify independent risk factors for mortality; using these data, the IMV Mortality Prediction Score (IMPRES) scoring system was developed. Results The following cut-off scores were used to indicate mortality risk: <2, low risk; 2–5, moderate risk; 5.1–8, high risk; >8, very high risk. There was a 26.8% mortality rate among the 254 patients who had a total IMPRES score of lower than 2. The mortality rate was 93.3% for patients with total IMPRES scores of greater than 8 (P < 0.001). Conclusion The present study included a large number of patients from various geographical areas of the country who were admitted to various types of ICUs, had diverse diagnoses and comorbidities, were intubated with various indications in either urgent or elective settings, and were followed by physicians from various specialties. Therefore, our data are more general and can be applied to a broader population. This study devised a new scoring system for decision-making for critically ill patients as to whether they need to be intubated or not and presents a rapid and accurate prediction of mortality and prognosis prior to ICU admission using simple clinical data.
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Affiliation(s)
- Tevfik ÖZLÜ
- Department of Chest Diseases, Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
| | - Mehtap PEHLİVANLAR KÜÇÜK*
- Department of Chest Diseases, Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
- Department of Chest Diseases, Division of Intensive Care Medicine, Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
- * To whom correspondence should be addressed. E-mail:
| | - Akın KAYA
- Department of Chest Diseases, Faculty of Medicine, Ankara University, AnkaraTurkey
| | - Esra YARAR
- Department of Chest Diseases, Necip Fazıl City Hospital, KahramanmaraşTurkey
| | - Cenk KIRAKLI
- Department of Chest Diseases, İzmir Dr Suat Seren Thoracic Diseases and Surgery Training and Research Hospital, İzmirTurkey
| | - Özlem ŞENGÖREN DİKİŞ
- Department of Chest Diseases, Bursa Yüksek İhtisas Training and Research Hospital, University of Health Sciences, BursaTurkey
| | - Hale KEFELİ ÇELİK
- Department of Anesthesiology and Reanimation, Samsun Training and Research Hospital, SamsunTurkey
| | - Serdar ÖZKAN
- Department of Thoracic Surgery, Faculty of Medicine, Karatay University, KonyaTurkey
| | - Hayriye BEKTAŞ AKSOY
- Department of Chest Diseases, Prof. Dr. A. İlhan Özdemir Training and Research Hospital, Giresun University, GiresunTurkey
| | - Ahmet Oğuzhan KÜÇÜK
- Department of Anesthesiology and Reanimation, Division of Intensive Care Medicine,Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
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18
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Choi Y, Kim JW, Suh KJ, Lim YJ, Lee JY, Kang BD, Kim JW, Kim SH, Lee JO, Kim YJ, Lee KW, Kim JH, Bang SM, Lee JS. Identification of a potentially avoidable cardiopulmonary resuscitation in hematology and oncology wards. BMC Palliat Care 2019; 18:93. [PMID: 31684934 PMCID: PMC6829942 DOI: 10.1186/s12904-019-0477-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/15/2019] [Indexed: 11/23/2022] Open
Abstract
Background In-hospital cardiopulmonary resuscitation (CPR) is one of undesirable situations. We tried to identify and characterize a potentially avoidable CPR in cancer patients who were hospitalized in hematology and oncology wards. Methods A potentially avoidable CPR was determined based on chemotherapy setting, disease status and clinical situation at the time when a cardiopulmonary arrest occurred, by using a consensus-driven medical records review of two physicians. Results One hundred thirty-seven patients among 12,437 patients hospitalized at hematology and oncology wards between March 2003 and June 2015 (1.1%) underwent a CPR. Eighty-eight patients (64.2%) were men. The majority of patients with a CPR had lung cancer (41, 29.9%), hematologic malignancy (24, 17.5%), stomach cancer (23, 16.8%) or lymphoma (20, 14.6%). A potentially avoidable CPR was identified in 51 patients (37.2%). In a multivariate analysis, advanced diseases and certain tumor types (e.g., lung cancer, lymphoma) were significant risk factors for a potentially avoidable CPR. Of patients who received a potentially avoidable CPR, 29 patients (56.9%) did not have a do-not-resuscitate documentation. A first return of spontaneous circulation rate (ROSC) and in-hospital survival rate (IHSR) were much lower in patients with a potentially avoidable CPR than those with a CPR that was not avoidable (ROSC: 39.2% vs 53.5%, P = 0.106; IHSR: 2.0% vs 12.8%, P = 0.032, respectively). Conclusions A potentially avoidable CPR was common at hematology and oncology wards. A potentially avoidable CPR frequently occurred in advanced diseases and certain tumor types. Furthermore, cancer patients who received a potentially avoidable CPR showed the worse prognosis.
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Affiliation(s)
- Yeonjoo Choi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.,Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.,Present Address: Department of Investigational Cancer Therapeutics, The MD Anderson Cancer Center, Houston, TX, USA
| | - Jin Won Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.
| | - Koung Jin Suh
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Yoo-Joo Lim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.,Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yun Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Beo-Deul Kang
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea.,Present Address: CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Ji-Won Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Se-Hyun Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Jeong-Ok Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Keun-Wook Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Jee Hyun Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Soo-Mee Bang
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
| | - Jong Seok Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 13620, Republic of Korea
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19
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Wilson ME, Mittal A, Karki B, Dobler CC, Wahab A, Curtis JR, Erwin PJ, Majzoub AM, Montori VM, Gajic O, Murad MH. Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis. Intensive Care Med 2019; 46:36-45. [PMID: 31659387 PMCID: PMC7223954 DOI: 10.1007/s00134-019-05828-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/07/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure. METHODS We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019. RESULTS Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate. CONCLUSIONS One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.
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Affiliation(s)
- Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA. .,Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | - Aniket Mittal
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bibek Karki
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Claudia C Dobler
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Institute for Evidence-Based Healthcare, Bond University and Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Abdul Wahab
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | | | - Abdul M Majzoub
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
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20
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Chang YC, Fang YT, Chen HC, Lin CY, Chang YP, Chen YM, Huang CH, Huang KT, Chang HC, Su MC, Wang YH, Wang CC, Lin MC, Fang WF. Effect of do-not-resuscitate orders on patients with sepsis in the medical intensive care unit: a retrospective, observational and propensity score-matched study in a tertiary referral hospital in Taiwan. BMJ Open 2019; 9:e029041. [PMID: 31209094 PMCID: PMC6589004 DOI: 10.1136/bmjopen-2019-029041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine whether do-not-resuscitate (DNR) orders affect outcomes in patients with sepsis admitted to intensive care unit (ICU). DESIGN This is a retrospective observational study. PARTICIPANTS We enrolled 796 consecutive adult intensive care patients at Kaohsiung Chang Gung Memorial Hospital, a 2700-bed tertiary teaching hospital in southern Taiwan. A total of 717 patients were included. MAIN MEASURES Clinical factors such as age, gender and other clinical factors possibly related to DNR orders and hospital mortality were recorded. KEY RESULTS There were 455 patients in the group without DNR orders and 262 patients in the group with DNR orders. Within the DNR group, patients were further grouped into early (orders signed on intensive care day 1, n=126) and late (signed after day 1, n=136). Patients in the DNR group were older and more likely to have malignancy than the group without DNR orders. Mortality at days 7, 14 and 28, as well as intensive care and hospital mortality, were all worse in these patients even after propensity-score matching. There were higher Charlson Comorbidity Index in the emergency room, but better outcomes in those with early-DNR orders compared with late-DNR orders. CONCLUSIONS DNR orders may predict worse outcomes for patients with sepsis admitted to medical ICUs. The survival rate in the early-DNR order group was not inferior to the late-DNR order group.
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Affiliation(s)
- Ya-Chun Chang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Tang Fang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hung-Cheng Chen
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiung-Yu Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ping Chang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chi-Han Huang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Tung Huang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huang-Chih Chang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mao-Chang Su
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yi-Hsi Wang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chin-Chou Wang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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21
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Malek MM, Abdul Rahman NN, Hasan MS, Haji Abdullah L. Islamic Considerations on the Application of Patient's Autonomy in End-of-Life Decision. JOURNAL OF RELIGION AND HEALTH 2018; 57:1524-1537. [PMID: 29417395 DOI: 10.1007/s10943-018-0575-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In end-of-life situation, the need for patient's preference comes into the picture with the intention of guiding physicians in the direction of patient care. Preference in medical directive is made by a person with full mental capacity outlining what actions should be taken for his health should he loses his competency. This is based on the reality of universal paradigm in medical practice that emphasises patient's autonomy. A specific directive is produced according to a patient's wish that might include some ethically and religiously controversial directives such as mercy killing, physician-assisted suicide, forgoing life-supporting treatments and do-not-resuscitate. In the future, patient autonomy is expected to become prevalent. The extent of patient autonomy has not been widely discussed among Muslim scholars. In Islam, there are certain considerations that must be adhered to.
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Affiliation(s)
- Mohammad Mustaqim Malek
- Department of Fiqh and Usul, Academy of Islamic Studies, University of Malaya, 50603, Kuala Lumpur, Malaysia.
- Centre for Science and Environment Studies, Institute of Islamic Understanding Malaysia, No. 2, Langgak Tunku, Off Jalan Tuanku Abdul Halim, 50480, Kuala Lumpur, Malaysia.
| | - Noor Naemah Abdul Rahman
- Department of Fiqh and Usul, Academy of Islamic Studies, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Luqman Haji Abdullah
- Department of Fiqh and Usul, Academy of Islamic Studies, University of Malaya, 50603, Kuala Lumpur, Malaysia
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22
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Ganz FD, Sharfi R, Kaufman N, Einav S. Perceptions of slow codes by nurses working on internal medicine wards. Nurs Ethics 2018; 26:1734-1743. [DOI: 10.1177/0969733018783222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Cardio-pulmonary resuscitation is the default procedure during cardio-pulmonary arrest. If a patient does not want cardio-pulmonary resuscitation, then a do not attempt resuscitation order must be documented. Often, this order is not given; even if thought to be appropriate. This situation can lead to a slow code, defined as an ineffective resuscitation, where all resuscitation procedures are not performed or done slowly. Research objectives: To describe the perceptions of nurses working on internal medicine wards of slow codes, including the factors associated with its implementation. Research design: This was a cross-sectional, descriptive study. Participants completed a personal characteristics questionnaire and the Perceptions and Factors of Slow Codes questionnaire designed for this study. Participants and research context: The sample was a convenience sample of nurses working on internal medicine wards in two Israeli hospitals. Ethical considerations: The study received ethical approval from both institutions, where data were collected and stored according to institutional policy. Findings: Most reported that resuscitations were conducted according to protocol (n = 90, 76.2%). Some took their time calling the code (n = 22, 18.3%), or waited by the bedside and did not perform cardio-pulmonary resuscitation (n = 45, 37.5%). Factors most associated with slow codes were poor patient prognosis (mean = 3.52/5, standard deviation = 1.27) and a low chance of patient survival (mean = 3.37/5, standard deviation = 1.21). Two-thirds (n = 76, 66.8%) reported that slow codes were done on their unit and the majority (n = 80, 69%) perceived slow codes as ethical. Discussion: This study confirms that slow codes are part of medical care on internal medicine wards, where most nurses perceive them as an ethical alternative. These perceptions are in contrast to most legal and ethical opinions expressed in the literature. Conclusion: Nurses should be educated about the legal and ethical implications of slow codes, and qualitative and quantitative studies should be conducted that further investigate its implementation.
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Affiliation(s)
| | | | | | - Sharon Einav
- Shaare Zedek Medical Centre, Israel; The Hebrew University of Jerusalem, Israel
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23
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Tseng YP, Huang LH, Hsu LL, Huang TH, Hsieh SI, Chi SF, Chou YF. The family surrogates' psychological experience of making a do-not-resuscitate decision for older relatives: a qualitative study. Contemp Nurse 2018; 54:195-207. [PMID: 29845875 DOI: 10.1080/10376178.2018.1478232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Many nursing home residents lack autonomous decision-making capacity and rely on family members to make do-not-resuscitate (DNR) decisions. Making DNR decisions can be difficult and complicated for surrogates. However, surrogates' psychological experience in making these decisions for older relatives is not well studied. AIM To understand the surrogates' psychological experience of making DNR decisions for older relatives in a nursing home. METHODS The study subjects of this qualitative study were family surrogates of older residents in a nursing home of Taiwan. A self-constructed, semi-structured interview guided in-depth interviews, which were recorded. Content analysis was used to discover themes from verbatim record. RESULTS Four themes were revealed: lack of psychological preparation, considering issues when making a decision, ambivalent emotional responses and impact of cultural factors. Fifteen subthemes were also found. CONCLUSIONS Surrogates who must decide whether to make a DNR decision for older relatives experience great emotional conflict. Understanding surrogates' struggles may assist nursing and care staff in managing this difficult situation.
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Affiliation(s)
- Yi-Ping Tseng
- a Medical College , National Taiwan University , Taipei , Taiwan.,b Taoyuan Chang Gung Memorial Hospital, Nursing Home , Chang Gung Medical Foundation , No. 26-8, Dongjiulukeng, Guishan Dist., Taoyuan , Taiwan, R.O.C
| | - Lian-Hua Huang
- c School of Nursing , University of Colorado , Boulder , Colorado.,d College of Medicine, Department of Nursing , National Taiwan University , No. 1, Sec 1, Jen-Ai Rd, Taipei , Taiwan, R.O.C
| | - Li-Ling Hsu
- e Teacher College , Columbia University , New York , NY , USA.,f Department of Nursing , Oriental Institute of Technology , , No.58, Sec. 2, Sichuan Rd., Banqiao Dist., New Taipei City 220, Taipei , Taiwan, R.O.C
| | - Tzu-Hsin Huang
- g Graduate Institute of Nursing , Taipei Medical University , Taipei , Taiwan.,h Taoyuan Chang Gung Memorial Hospital, Nursing Department , Chang Gung Medical Foundation , No.123, Dinghu Rd., Guishan Dist., Taoyuan , Taiwan, R.O.C
| | - Suh-Ing Hsieh
- i School of Nursing , University of Maryland at Baltimore , Baltimore , MD , USA.,j Nursing Department at Chang Gung University of Science and Technology, Taoyuan Chang Gung Memorial Hospital , N423, No. 261, Wenhwa 1st Road, Kweishan, Taoyuan , Taiwan, R.O.C
| | - Shu-Fen Chi
- k Department of Health Care Management , Chang Gung University , Taoyuan , Taiwan.,l Taoyuan Chang Gung Memorial Hospital, Nursing Department , Chang Gung Medical Foundation , Nursing supervisor, No. 123, Dinghu Rd., Guishan Dist., Taoyuan , Taiwan, R.O.C
| | - Yen-Fang Chou
- m Department of Nursing , Chang Gung University , Taoyuan , Taiwan.,n Taoyuan Chang Gung Memorial Hospital, Nursing Department , Chang Gung Medical Foundation , Nursing supervisor, No.123, Dinghu Rd., Guishan Dist., Taoyuan , Taiwan, R.O.C
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24
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Wang AY, Ma HP, Kao WF, Tsai SH, Chang CK. Characteristics and outcomes of "Do Not Resuscitate" patients admitted to the emergency department-Intensive care unit. J Formos Med Assoc 2018; 118:223-229. [PMID: 29731386 DOI: 10.1016/j.jfma.2018.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 03/21/2018] [Accepted: 03/28/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Appropriate utilization of intensive care unit (ICU) beds are essential. Patients with critical illness who have do not resuscitate (DNR) have a reduced priority of intensive care. However, the possibility of recovery/survival is ambiguous and multifactorial. OBJECTIVE To deliberate the characteristics and outcomes of critical illness in patients with prior DNR who were admitted to the emergency department (ED)-ICU. METHOD This was a retrospective cohort study conducted between April 2015 and November 2015 in a university-based hospital. Non-traumatic patients with DNR admitted to ED-ICU from ED were included. RESULTS Seventy-eight non-trauma patients with prior DNR status were included in the final analysis. 51.3% (40/78) patients were male with median age 83 (IQR: 75-89) years. The median APACHE II score was 24.5 (IQR: 20-30). 50% (39/78) of the DNR patients survived to discharge. Patients who survived to discharge had lower APACHE II score (23 (IQR: 20-28) vs. 28 (18-38), p = 0.028). There was no significant difference in age, gender, and Charlson index. ROC curves were constructed, generating a cut-off of the APACHE II score at 29.5 for determining survival to discharge (AUC = 0.644, p = 0.028). In multivariate Cox proportional model, APACHE II score above 29.5 was an independent predictor for mortality. (Hazard ratio = 2.46; 95% confidence interval: 1.04-5.83, p = 0.042). CONCLUSION Our study found that 50% of patients with prior DNR on ICU admission survived to discharge, indicating that aggressive care is not definitely futile. Further prospective studies are required to evaluate the cost-effectiveness and patients' and/or families' satisfaction of the ICU admission of DNR patients.
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Affiliation(s)
- An-Yi Wang
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Hon-Ping Ma
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Shuang Ho Hospital, New-Taipei City, Taiwan
| | - Wei-Fong Kao
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Shin-Han Tsai
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Emergency Medicine, Shuang Ho Hospital, New-Taipei City, Taiwan
| | - Cheng-Kuei Chang
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei City, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, New-Taipei City, Taiwan.
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25
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Huang BY, Chen HP, Wang Y, Deng YT, Yi TW, Jiang Y. The do-not-resuscitate order for terminal cancer patients in mainland China: A retrospective study. Medicine (Baltimore) 2018; 97:e0588. [PMID: 29718859 PMCID: PMC6392573 DOI: 10.1097/md.0000000000010588] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
With the development of palliative care, a signed do-not-resuscitate (DNR) order has become increasingly popular worldwide. However, there is no legal guarantee of a signed DNR order for patients with cancer in mainland China. This study aimed to estimate the status of DNR order signing before patient death in the cancer center of a large tertiary affiliated teaching hospital in western China. Patient demographics and disease-related characteristics were also analyzed.This was a retrospective chart analysis. We screened all charts from a large-scale tertiary teaching hospital in China for patients who died of cancer from January 2010 to February 2015. Analysis included a total of 365 records. The details of DNR order forms, patient demographics, and disease-related characteristics were recorded.The DNR order signing rate was 80%. Only 2 patients signed the DNR order themselves, while the majority of DNR orders were signed by patients' surrogates. The median time for signing the DNR order was 1 day before the patients' death. Most DNR decisions were made within the last 3 days before death. The time at which DNR orders were signed was related to disease severity and the rate of disease progression.Our findings indicate that signing a DNR order for patients with terminal cancer has become common in mainland China in recent years. Decisions about a DNR order are usually made by patients' surrogates when patients are severely ill. Palliative care in mainland China still needs to be improved.
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Affiliation(s)
- Bo-Yan Huang
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Hui-Ping Chen
- Department of Palliative Medicine, West China Fourth Hospital, Sichuan University
| | - Ying Wang
- Department of Medical Oncology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, People's Republic of China
| | - Yao-Tiao Deng
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Ting-Wu Yi
- Department of Medical Oncology, Cancer Center, West China Hospital
| | - Yu Jiang
- Department of Medical Oncology, Cancer Center, West China Hospital
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26
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Reid L, Kydd A, Slade B. An inquiry into what organised difficult advance care planning conversations in a Scottish residential care home using institutional ethnography. J Res Nurs 2018; 23:220-236. [PMID: 34394426 DOI: 10.1177/1744987118756477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aim This paper provides an institutional ethnographic analysis of how advance care planning discussions, which included advance decisions about serious illness, hospital admission and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms, were systematically placed into the hands of senior social care workers (SSCWs) in a residential care home (RCH). RCHs are care settings where there are no on-site nurses, and access to hospital and/or community doctors and nurses is limited. Methods The paper traces the organising features of day-to-day work gathered from interviews with SSCWs (n = 4) and others (n = 6) whose (well-intentioned) work shaped what happened in the RCH. Results It shows how the experience of SSCWs was socially organised to happen as it did as they (and others) complied with powerful organising texts such as national and local policy documents, care plans and audit forms. The paper concludes that although SSCWs decision-making conversations were out of alignment with the national DNACPR policy, they cannot simply be described as poor practice. This is because they were socially organised by a complex web of institutional practices related to the occupancy rate in the RCH, the inspection process of the care home scrutiny body, the quality assurance process of the RCH company, the funding of palliative care education, and powerful political and fiscal drives to reduce spending on over-75s. These practices had little to do with the actual care needs of RCH residents or the actual support needs of RCH staff. Conclusions The paper points towards necessary policy changes. It also highlights how 'competent' work driven by ideological institutional practices can result in ethically troubling situations in day-to-day working life. This emphasises the importance of carefully examining the social organisation of situations typically described as poor practice if we are to understand how they are (re)produced. It also offers a different account of care home deaths than is typically presented in the professional literature.
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Affiliation(s)
- Lorna Reid
- School of Health and Social Care, Edinburgh Napier University, UK
| | - Angela Kydd
- School of Health and Social Care, Edinburgh Napier University, UK
| | - Bonnie Slade
- School of Adult Education, University of Glasgow, UK
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Zaal-Schuller IH, Willems DL, Ewals FVPM, van Goudoever JB, de Vos MA. Considering quality of life in end-of-life decisions for severely disabled children. RESEARCH IN DEVELOPMENTAL DISABILITIES 2018; 73:67-75. [PMID: 29268163 DOI: 10.1016/j.ridd.2017.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND End-of-life decisions (EoLDs) are very difficult to make. How parents and physicians incorporate quality of life (QoL) considerations into their end-of-life decision making (EoLDM) for children with profound intellectual and multiple disabilities (PIMD) remains unknown. AIMS To determine which elements contribute to QoL according to parents and physicians, how QoL is incorporated into EoLDM and how parents and physicians discuss QoL considerations in the Netherlands. METHODS Semi-structured interviews were conducted with the physicians and parents of 14 children with PIMD for whom an EoLD had been made within the past two years. RESULTS Parents and physicians agreed on the main elements that contribute to QoL in children with PIMD. The way in which QoL was incorporated differed slightly for different types of decisions. Parents and physicians rarely discussed elements contributing to the child's QoL when making EoLDS. CONCLUSIONS and Implications Although QoL was highly important during EoLDM for children with PIMD, parents and physicians did not fully explore the elements that contribute to the child's QoL when they made EoLDs. We recommend the development of a communication tool that will help parents and physicians discuss elements that contribute to QoL and the consequences these elements have for upcoming decisions.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey. Support Care Cancer 2017; 26:1773-1780. [DOI: 10.1007/s00520-017-4014-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/05/2017] [Indexed: 01/08/2023]
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Alrimawi I, Saifan AR, Abdelkader R, Batiha AM. Palestinian community perceptions of do-not-resuscitation order for terminally Ill patients: A qualitative study. J Clin Nurs 2017; 27:2719-2728. [PMID: 28557015 DOI: 10.1111/jocn.13905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 12/21/2022]
Abstract
AIM AND OBJECTIVES To illustrate the Palestinian community's views, opinions and stances about the concept of do-not-resuscitate for terminally ill patients. BACKGROUND Do-not-resuscitate orders are practised in many countries worldwide, but there is no consensus on their practice in the Middle East. Do-not-resuscitate orders may be applied for terminally ill paediatric patients. Some studies have been conducted describing people's experiences with these do-not-resuscitate orders. However, few studies have considered community perspectives on do-not-resuscitate orders for terminally ill patients in Palestine. DESIGN A descriptive-qualitative design was adopted. METHODS A purposive sample of 24 participants was interviewed, with consideration of demographical characteristics such as age, gender, education and place of residency. The participants were recruited over a period of 6 months. Individual semistructured interviews were utilised. These interviews were transcribed and analysed using thematic analysis. FINDINGS Significantly, the majority of the participants did not know the meaning of do-not-resuscitate and thought that removal of life-sustaining devices and do-not-resuscitate were the same concept. Most of the interviewees adopted stances against do-not-resuscitate orders. Several factors were suggested to influence the decision of accepting or rejecting the do-not-resuscitate order. The majority of the participants mentioned religion as a major factor in forming their viewpoints. The participants expressed different views regarding issuing a law regarding do-not-resuscitate orders. CONCLUSION Our findings provide a unique understanding that there is a general misunderstanding among our participants regarding the do-not-resuscitate order. Further research with policymakers and stakeholders is still required.
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Affiliation(s)
| | | | - Raghad Abdelkader
- School of Nursing, Applied Science Private University, Amman, Jordan
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Abstract
PURPOSE OF REVIEW Decisions to forego life-sustaining treatments are complex, and disagreements between physicians and patients occur. This review discusses recent findings regarding what factors influence physicians and patients or their surrogates in these decisions and considers whether futility arguments regarding life-sustaining treatments should be abandoned. RECENT FINDINGS Cardiopulmonary resuscitation is one paradigm in the literature for studying end-of-life decision-making. Outcomes for cardiopulmonary resuscitation are poor, and physicians tend to over-rely on tacit versus evidence-based knowledge for resuscitation decisions. Physician decisions are often inherently biased regarding elderly and intellectually impaired patients. Patient decisions regarding life-sustaining treatments are poorly understood by physicians, and also include inherent bias against the elderly and intellectually impaired. Although patients and their decision-makers frequently incorporate religious or spiritual beliefs in their decisions, physicians rarely discuss these factors with them. Defining 'futility' is problematic, and futility arguments have limited utility in clinical end-of-life treatment discussions. SUMMARY Further research is needed about factors that affect both physicians and patients with regard to forgoing life-sustaining interventions. Physicians need more information regarding religious/spiritual preferences of patients and decision-makers. 'Futility' arguments in end-of-life decision-making are flawed and should probably be abandoned.
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Affiliation(s)
- Gail A Van Norman
- Department of Anesthesiology and Pain Medicine and as Adj Professor of Bioethics, University of Washington, Seattle, Washington, USA
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Tsai HH, Tsai YF, Liu CY. Advance directives and mortality rates among nursing home residents in Taiwan: A retrospective, longitudinal study. Int J Nurs Stud 2016; 68:9-15. [PMID: 28033524 DOI: 10.1016/j.ijnurstu.2016.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 12/10/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND No data-based evidence is available regarding the best time for nursing home nurses to obtain residents' signatures on advance directives, especially for do-not-resuscitate directives, the most common type of advance directive. This information is needed to enhance the low prevalence of advance directives in Asian countries. OBJECTIVES The purposes of this study were to understand (1) the timing between nursing home admission and signing a do-not-resuscitate directive, (2) the factors related to having a do-not-resuscitate directive, and (3) the association between having a do-not-resuscitate directive and nursing home residents' mortality in Taiwan. DESIGN Retrospective, longitudinal design. SETTING Six nursing homes in Taiwan. PARTICIPANTS Nursing home residents (N=563). METHODS Data were collected by retrospective chart review with 1-year follow-up. Factors related to having a do-not-resuscitate directive were analyzed by multiple logistic regression, while associations between signing a do-not-resuscitate directive (resuscitation preference) and mortality were examined by Cox proportional hazard regression models. RESULTS The mean interval between nursing home admission and signing a do-not-resuscitate directive was 840.65days (2.30 years), which was longer than the time from admission to first transfer to hospital (742.4days). Having a do-not-resuscitate directive was related to whether the resident had a nasogastric tube (odds=2.57) and the number of transfers to hospital (odds=1.18). Among the 563 residents, 55 (9.77%) had died at the 1-year follow-up. Having a do-not-resuscitate directive was associated with a greater risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.10-3.98; p=0.02), but this risk did not persist after adjusting for age (hazard ratio, 1.89; 95% confidence interval, 0.99-3.59; p=0.05). CONCLUSION Early research recommendations to sign an advance directive, particularly a do-not-resuscitate order, on nursing home admission may not be the best time for Chinese nursing home residents. Our results suggest that the best time to sign a do-not-resuscitate directive is as early as possible and no later than 2 years (742days) after admission if residents had not already done so. Residents on nasogastric tube feeding should be particularly targeted for discussions about do-not-resuscitate directives.
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Affiliation(s)
- Hsiu-Hsin Tsai
- School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Yun-Fang Tsai
- School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital, Keelung, Taiwan.
| | - Chia-Yih Liu
- Department of Psychiatry, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; Department of Medicine, Chang Gung University, Tao-Yuan, Taiwan
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Gulacti U, Lok U. Influences of "do-not-resuscitate order" prohibition on CPR outcomes. Turk J Emerg Med 2016; 16:47-52. [PMID: 27896320 PMCID: PMC5121282 DOI: 10.1016/j.tjem.2016.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/15/2016] [Accepted: 03/23/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of the study is to determine factors affecting the return of spontaneous circulation (ROSC) ratios, neurological outcomes at discharge, the ratio of living patients discharged from the hospital and due to Do not attempt resuscitation (DNAR) prohibition. MATERIAL AND METHODS This is a retrospective observational study conducted on patients of cardiopulmonary resuscitation (CPR) performed in emergency department (ED) and intensive care units between February 2010 and February 2012. RESULTS A total of 469 patients were evaluated, and 266 eligible patients who did not have DNAR orders were included in the study. Overall, 45.1% of the adult in-hospital cardiac arrest victims returned to spontaneous circulation, and 5.3% survived to hospital discharge. Of the patients who were discharged alive from the hospital, 33.3% were discharged in poor neurologic conditions of Cerebral Performance Category (CPC) score 3 or 4. The ROSC ratio was reduced for the patients with malignancies compared to the patients with other preexisting conditions (OR: 12.783; 95% CI 2.967-55.072; p = 0.000). None of the patients with malignancies were discharged alive from the hospital. Only one patient with end-stage disease was discharged alive from hospital, and this patient's CPC score was 4. DISCUSSION AND CONCLUSION CPR has not increased the ROSC and alive discharge rates in patients with malignancy and end-state disease. DNAR order prohibition have been increased the futile CPR attempts. DNAR should be accepted as a human right that represents an honorable death option and whether a DNAR is order demanded should be specifically discussed with patients with malignancies and end-stage disease presenting to ED.
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Affiliation(s)
- Umut Gulacti
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
| | - Ugur Lok
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
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Ruiz-García J, Canal-Fontcuberta I, Martínez-Sellés M. Las órdenes de no reanimar. Historia y situación actual. Med Clin (Barc) 2016; 147:316-20. [DOI: 10.1016/j.medcli.2016.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 12/21/2022]
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Huang CT, Chuang YC, Tsai YJ, Ko WJ, Yu CJ. High Mortality in Severe Sepsis and Septic Shock Patients with Do-Not-Resuscitate Orders in East Asia. PLoS One 2016; 11:e0159501. [PMID: 27416064 PMCID: PMC4944975 DOI: 10.1371/journal.pone.0159501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 07/05/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Severe sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan. METHODS A retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care. RESULTS Sixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66-14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients. CONCLUSIONS From the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients.
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Affiliation(s)
- Chun-Ta Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ju Tsai
- Graduate Institute of Biomedical and Pharmaceutical Science, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Wen-Je Ko
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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The "do-not-resuscitate" order in palliative surgery: Ethical issues and a review on policy in Hong Kong. Palliat Support Care 2016; 13:1489-93. [PMID: 26399748 DOI: 10.1017/s1478951514001370] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A do-not-resuscitate (DNR) order, or "advance directive," is commonly seen in the cases of palliative patients who express a wish to withhold specific resuscitative therapies in the event of a cardiac arrest. With recent technological advances, there are increasing numbers of palliative patients who undergo surgical interventions to treat their symptoms and discomfort. The decision to suspend DNR orders for palliative surgery is always a matter for debate. The present article describes a case and the ethical issues involved and gives some practical suggestions for those facing similar problems. We also review the latest DNR policy in Hong Kong.
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Zafar W, Ghafoor I, Jamshed A, Gul S, Hafeez H. Outcomes of In-Hospital Cardiopulmonary Resuscitation Among Patients With Cancer. Am J Hosp Palliat Care 2016; 34:212-216. [PMID: 26589879 DOI: 10.1177/1049909115617934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review all episodes where an emergency code was called in a cancer-specialized hospital in Pakistan and to assess survival to discharge among patients who received a cardiopulmonary resuscitation (CPR). METHODS We reviewed demographic and clinical data related to all "code blue" calls over 3 years. Multivariate logistic regression analyses were used to test the association of clinical characteristics with the primary outcome of survival to discharge. RESULTS A total of 646 code blue calls were included in the analysis. The CPR was performed in 388 (60%) of these calls. For every 20 episodes of CPR among patients with cancer of all ages, only 1 resulted in a patient's survival to discharge, even though in 52.2% episodes there was a return of spontaneous circulation. No association was found between the type of rhythm at initiation of CPR and likelihood of survival to discharge. CONCLUSIONS The proportion of patients with advanced cancer surviving to discharge after in-hospital CPR in a low-income country was in line with the reported international experience. Most patients with cancer who received in-hospital CPR did not survive to discharge and did not appear to benefit from resuscitation. Advance directives by patients with cancer limiting aggressive interventions at end of life and proper documentation of these directives will help in provision of care that is humane and consonant with patients' wishes for a dignified death. Patients' early appreciation of the limited benefits of CPR in advanced cancer is likely to help them formulate such advance directives.
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Affiliation(s)
- Waleed Zafar
- 1 Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Irum Ghafoor
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Arif Jamshed
- 3 Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Sabika Gul
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Haroon Hafeez
- 2 Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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Gibbs AJO, Malyon AC, Fritz ZBM. Themes and variations: An exploratory international investigation into resuscitation decision-making. Resuscitation 2016; 103:75-81. [PMID: 26976676 PMCID: PMC4879149 DOI: 10.1016/j.resuscitation.2016.01.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/17/2015] [Accepted: 01/25/2016] [Indexed: 10/31/2022]
Abstract
BACKGROUND Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made in hospitals throughout the globe. International variation in clinicians' perception of DNACPR decision-making and implementation and the factors influencing such variation has not previously been explored. METHODS A questionnaire asking how DNACPR decisions are made, communicated and perceived in their country was composed: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had 4 weeks to answer the questionnaire. RESULTS 78 responses (44%) were received from 43 countries. All continents were represented. 88% of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. 94% of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes towards death, medical education and culture, health economics and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions. CONCLUSIONS The majority of countries surveyed make some form of DNACPR decision but differing cultures and economic status contribute towards a heterogeneity of approaches to resuscitation decision-making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision-making and implementation.
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Affiliation(s)
| | - Alexandra C Malyon
- Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK
| | - Zoë B McC Fritz
- Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK; Warwick Medical School, University of Warwick Coventry, CV4 7AL, UK.
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Fujiwara S, Koike T, Moriyasu M, Nakagawa M, Atagi K, Lefor AK, Fujitani S, Ikeda T, Takamatsu Y, Hasegawa Y, Suzuki S, Komuro T, Kawamura N, Yamada N. A retrospective study of in-hospital cardiac arrest. Acute Med Surg 2016; 3:320-325. [PMID: 29123806 DOI: 10.1002/ams2.193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/30/2015] [Indexed: 11/09/2022] Open
Abstract
Aim In-hospital cardiac arrest is an important issue in health care today. Data regarding in-hospital cardiac arrest in Japan is limited. In Australia and the USA, the Rapid Response System has been implemented in many institutions and data regarding in-hospital cardiac arrest are collected to evaluate the efficacy of the Rapid Response System. This is a multicenter retrospective survey of in-hospital cardiac arrest, providing data before implementing a Rapid Response System. Methods Ten institutions planning to introduce a Rapid Response System were recruited to collect in-hospital cardiac arrest data. The Institutional Review Board at each participating institution approved this study. Data for patients admitted at each institution from April 1, 2011 until March 31, 2012 were extracted using the three keywords "closed-chest compression", "epinephrine", and "defibrillation". Patients under 18 years old, or who suffered cardiac arrest in the emergency room or the intensive care unit were excluded. Results A total of 228 patients in 10 institutions were identified. The average age was 73 ± 13 years. Males represented 64% of the patients (82/146). Overall survival after in-hospital cardiac arrest was 7% (16/228). Possibly preventable cardiac arrests represented 15% (33/228) of patients, with medical safety issues identified in 8% (19/228). Vital sign abnormalities before cardiac arrest were observed in 63% (138/216) of patients. Conclusions Approximately 60% of patients had abnormal vital signs before cardiac arrest. These patients may have an improved clinical outcome by implementing a Rapid Response System.
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Affiliation(s)
- Shinsuke Fujiwara
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
| | | | | | | | - Kazuaki Atagi
- Division of Patient Safety and Quality Nara Medical University Kashihara Nara Japan
| | - Alan K Lefor
- Department of Surgery Jichi Medical University Shimotsuke Tochigi Japan
| | | | | | - Takeshi Ikeda
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
| | - Yuka Takamatsu
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
| | - Yasuhisa Hasegawa
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
| | - Satoshi Suzuki
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
| | - Tetsya Komuro
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
| | - Natsuki Kawamura
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
| | - Narumi Yamada
- Department of Emergency Medicine NHO Ureshino Medical Center Ureshino Saga Japan
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Abdallah FS, Radaeda MS, Gaghama MK, Salameh B. Intensive Care Unit Physician's Attitudes on Do Not Resuscitate Order in Palestine. Indian J Palliat Care 2016; 22:38-41. [PMID: 26962279 PMCID: PMC4768448 DOI: 10.4103/0973-1075.173947] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: There is some ambiguity concerning the do-not-resuscitate (DNR) orders in the Arabic world. DNR is an order written by a doctor, approved by the patient or patient surrogate, which instructs health care providers to not do CPR when cardiac or respiratory arrest occurs. Therefore, this research study investigated the attitudes of Intensive Care Unit physicians and nurses on DNR order in Palestine. Materials and Methods: A total of 123 males and females from four different hospitals voluntarily participated in this study by signing a consent form; which was approved by the Ethical Committee at Birzeit University and the Ministry of Health. A non-experimental, quantitative, descriptive, and co-relational method was used, the data collection was done by a three page form consisting of the consent form, demographical data, and 24 item-based questionnaire based on a 5-point-Likert scale from strongly agree (score 1) to strongly disagree (score 5). Results: The Statistical Package for Social Sciences (SPSS) software program version 17.0 was used to analyze the data. Finding showed no significant relationship between culture and opinion regarding the DNR order, but religion did. There was statistical significance difference between the physicians’ and nurses’ religious beliefs, but there was no correlation. Moreover, a total of 79 (64.3%) physicians and nurses agreed with legalizing the DNR order in Palestine. Conclusion: There was a positive attitude towards the legalization of the DNR order in Palestine, and culture and religion did not have any affect towards their attitudes regarding the legalization in Palestine.
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Affiliation(s)
| | | | | | - Basma Salameh
- Department of Nursing, Birzeit University, Palestine
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김원정, 강지숙. A Comparison of the Understanding of the Withdrawal of Life-sustaining Treatment between Intensive Care Unit Nurses and Patients’ Family Members. ACTA ACUST UNITED AC 2015. [DOI: 10.35301/ksme.2015.18.4.424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Limitation of care orders in patients with a diagnosis of dementia. Resuscitation 2015; 98:118-24. [PMID: 25818706 DOI: 10.1016/j.resuscitation.2015.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/11/2015] [Accepted: 03/16/2015] [Indexed: 11/22/2022]
Abstract
The prevalence of dementia is growing with an ageing population. Most persons with dementia die of acute illness and many are hospitalised at the end of life. In the acute hospital setting, limitation of care orders (LCOs) such as Do Not Attempt CPR and Physician Orders For Life Sustaining Treatment (POLST), appear to be underused in patients with dementia. These patients receive the same aggressive life-prolonging therapies as any other patient, despite drastically higher mortality. However, limitation of care orders in patients with dementia is not addressed by current guidelines or policies. Systems and processes for obtaining and documenting LCO need improvement at the individual, organisational and societal level. The issue is controversial amongst the public and poorly understood by clinicians. Balanced and empathetic decision-making requires an individualised approach and recognition of the complexities (legal, ethical and clinical) of this issue. We examine the domains of: (a) treatment effectiveness, (b) burden of care and quality of life and (c) patient autonomy and capacity.
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Cohen CJ, Chen Y, Orbach H, Freier-Dror Y, Auslander G, Breuer GS. Social values as an independent factor affecting end of life medical decision making. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:71-80. [PMID: 24965073 DOI: 10.1007/s11019-014-9581-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Research shows that the physician's personal attributes and social characteristics have a strong association with their end-of-life (EOL) decision making. Despite efforts to increase patient, family and surrogate input into EOL decision making, research shows the physician's input to be dominant. Our research finds that physician's social values, independent of religiosity, have a significant association with physician's tendency to withhold or withdraw life sustaining, EOL treatments. It is suggested that physicians employ personal social values in their EOL medical coping, because they have to cope with existential dilemmas posed by the mystery of death, and left unresolved by medical decision making mechanisms such as advanced directives and hospital ethics committees.
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Affiliation(s)
- Charles J Cohen
- Department of Medicine, Shaare Zedek Medical Center, P o Box 3235, 91031, Jerusalem, Israel
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Khalaileh MA. Jordanian critical care nurses' attitudes toward and experiences of do not resuscitate orders. Int J Palliat Nurs 2014; 20:403-8. [PMID: 25151868 DOI: 10.12968/ijpn.2014.20.8.403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Do not resuscitate (DNR) decisions are an issue of considerable sensitivity for patients and their relatives, as well as health professionals. PURPOSE The aim of this study was to explore Jordanian critical care nurses' attitudes towards and experiences of DNR decisions in clinical practice. METHODS A cross-sectional survey design was used. The sample consisted of 111 nurses working in intensive care units in three government hospitals in Jordan. RESULTS Fifty nine per cent of the participants were female. Most were under the age of 35 (69%) and 75% had a bachelor's degree. Most (67%) thought that the patient's family should be involved in DNR decision making. The majority (81%) reported that they preferred a coding system documenting DNR decisions in either the physician or nursing notes. Fifty eight per cent agreed that a standard DNR form should be kept with the patient's medical notes. Only 21% reported actual participation in DNR decisions. CONCLUSION This study demonstrates that Jordanian critical care nurses are willing to participate in DNR discussions and decision-making processes. Each hospital in the country should have a written DNR policy to guide and discipline health-care providers' practice.
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Affiliation(s)
- Murad Al Khalaileh
- Assistant Professor, School of Nursing, Al al-Bayt University, PO Box 130040, Mafraq 25113, Jordan
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Field RA, Fritz Z, Baker A, Grove A, Perkins GD. Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions. Resuscitation 2014; 85:1418-31. [DOI: 10.1016/j.resuscitation.2014.08.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/03/2014] [Accepted: 08/16/2014] [Indexed: 11/15/2022]
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Two decades of British newspaper coverage regarding do not attempt cardiopulmonary resuscitation decisions: Lessons for clinicians. Resuscitation 2014; 86:31-7. [PMID: 25449344 DOI: 10.1016/j.resuscitation.2014.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/08/2014] [Accepted: 10/05/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review UK newspaper reports relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in order to identify common themes and encourage dialogue. METHODS An online media database (LexisNexis(®)) was searched for UK Newspaper articles between 1993 and 2013 that referenced DNACPR decisions. Legal cases, concerning resuscitation decisions, were identified using two case law databases (Lexis Law(®) and Westlaw(®)), and referenced back to newspaper publications. All articles were fully reviewed. RESULTS Three hundred and thirty one articles were identified, resulting from 77 identifiable incidents. The periods 2000-01 and 2011-13 encompassed the majority of articles. There were 16 high-profile legal cases, nine of which resulted in newspaper articles. Approximately 35 percent of newspaper reports referred to DNACPR decisions apparently made without adequate patient and/or family consultation. "Ageism" was referred to in 9 percent of articles (mostly printed 2000-02); and "discrimination against the disabled" in 8 percent (mostly from 2010-12). Only five newspaper articles (2 percent) discussed patients receiving CPR against their wishes. Eighteen newspaper reports (5 percent) associated DNACPR decisions with active euthanasia. CONCLUSIONS Regarding DNACPR decision-making, the predominant theme was perceived lack of patient involvement, and, more recently, lack of surrogate involvement. Negative language was common, especially when decisions were presumed unilateral. Increased dialogue, and shared decision-making, is recommended.
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Kao CY, Wang HM, Tang SC, Huang KG, Jaing TH, Liu CY, Liu KH, Shen WC, Wu JH, Hung YS, Hsu HC, Chen JS, Liau CT, Lin YC, Su PJ, Hsieh CH, Chou WC. Predictive factors for do-not-resuscitate designation among terminally ill cancer patients receiving care from a palliative care consultation service. J Pain Symptom Manage 2014; 47:271-82. [PMID: 23856097 DOI: 10.1016/j.jpainsymman.2013.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/27/2013] [Accepted: 03/29/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Since the development of palliative care in the 1980s, "do not resuscitate" (DNR) has been promoted worldwide to avoid unnecessary resuscitation in terminally ill cancer patients. OBJECTIVES This study aimed to evaluate the effect of a palliative care consultation service (PCCS) on DNR designation and to identify a subgroup of patients who would potentially benefit from care by the PCCS with respect to DNR designation. METHODS In total, 2995 terminally ill cancer patients (with a predicted life expectancy of less than six months by clinician estimate) who received care by the PCCS between January 2006 and December 2010 at a single medical center in Taiwan were selected. Among these, the characteristics of 2020 (67.4%) patients who were not designated as DNR at the beginning of care by the PCCS were retrospectively analyzed to identify variables pertinent to DNR designation. RESULTS A total of 1301 (64%) of 2020 patients were designated as DNR at the end of care by the PCCS. Male gender and primary liver cancer were characteristics more predominantly found among DNR-designated patients who also had worse performance status, higher prevalence of physical distress, and shorter intervals from palliative care referral to death than did patients without DNR designation. On univariate analysis, a higher probability of DNR designation was associated with male gender, duration of care by the PCCS of more than 14 days, patients' prognostic awareness, family's diagnostic and prognostic awareness, and high Palliative Prognostic Index (PPI) scores. On multivariate analysis, duration of care by the PCCS, patients' prognostic awareness, family's diagnostic and prognostic awareness, and a high PPI score constituted independent variables predicting DNR-designated patients at the end of care by the PCCS. CONCLUSION DNR designation was late in terminally ill cancer patients. DNR-designated cancer patient indicators were high PPI scores, patients' prognostic awareness, family's diagnostic and prognostic awareness, and longer durations of care by the PCCS.
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Affiliation(s)
- Chen-Yi Kao
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Hung-Ming Wang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Shu-Chuan Tang
- Department of Nursing, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Kuan-Gen Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Tang-Her Jaing
- Division of Hematology and Oncology, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chien-Ying Liu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Keng-Hao Liu
- Department of Surgery, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Wen-Chi Shen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Jin-Hou Wu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Yu-Shin Hung
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Hung-Chih Hsu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chi-Ting Liau
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Yung-Chang Lin
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Po-Jung Su
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China.
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