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Comer AR, Jawed A, Roeder H, Kramer N. The impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke. J Stroke Cerebrovasc Dis 2024; 33:107820. [PMID: 38876458 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES In this review, we examine the impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke and discuss the current theories, available evidence, and gaps in the literature. METHODS A scoping review of the literature was conducted to determine gender differences on advanced stroke interventions and end-of-life outcomes after stroke. The study team utilized PubMed to conduct a review of the literature and included research studies related to sex, gender, advanced stroke interventions, and end-of-life outcomes after stroke. The PRISMA process for conducting a scoping review was followed. RESULTS This review found that although evidence regarding gender differences in advanced stroke interventions and end-of-life care after stroke is disparate, some gender differences do indeed exist. Women are less likely to receive thrombectomy or alteplase, women are more likely to receive palliative care intervention, hospice, and women experience stroke mortality at higher rates. CONCLUSIONS Gender differences in end-of-life care after stroke are apparent with women experiencing lower rates of life sustaining interventions, and higher rates of mortality, palliative and hospice care. More research is needed to identify variables associated with or responsible for gender differences during advance interventions and end-of-life care after stroke.
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Affiliation(s)
- Amber R Comer
- American Medical Association, Indiana University, United States.
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Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Med 2021; 9:20503121211000918. [PMID: 33786182 PMCID: PMC7958189 DOI: 10.1177/20503121211000918] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/12/2021] [Indexed: 11/16/2022] Open
Abstract
The goal of end-of-life care for dying patients is to prevent or relieve
suffering as much as possible while respecting the patients’ desires.
However, physicians face many ethical challenges in end-of-life care.
Since the decisions to be made may concern patients’ family members
and society as well as the patients, it is important to protect the
rights, dignity, and vigor of all parties involved in the clinical
ethical decision-making process. Understanding the principles
underlying biomedical ethics is important for physicians to solve the
problems they face in end-of-life care. The main situations that
create ethical difficulties for healthcare professionals are the
decisions regarding resuscitation, mechanical ventilation, artificial
nutrition and hydration, terminal sedation, withholding and
withdrawing treatments, euthanasia, and physician-assisted suicide.
Five ethical principles guide healthcare professionals in the
management of these situations.
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Affiliation(s)
- Melahat Akdeniz
- Department of Family Medicine, Faculty of Medicine, Akdeniz University Hospital, Akdeniz University, Antalya, Turkey
| | | | - Ethem Kavukcu
- Department of Sports Medicine, Faculty of Medicine, Akdeniz University Hospital, Akdeniz University, Antalya, Turkey
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Koşar I, Akdeniz M, Kavukcu E, Avci HH. Assessment of Knowledge and Preferences Regarding Advance Directives Among Patients in University Family Medicine Outpatient Clinics. Gerontol Geriatr Med 2020; 6:2333721420901902. [PMID: 32047835 PMCID: PMC6984430 DOI: 10.1177/2333721420901902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/09/2019] [Accepted: 12/19/2019] [Indexed: 11/16/2022] Open
Abstract
Aim: The aim of this study is to draw attention to the subject of "advanced directives," to create awareness, whether or not they want to investigate to determine the preferences for medical care and applications in the period of end-of-life while individuals can specify their preferences and wishes for medical decisions and take steps for it. Materials and Methods: The study was carried out on individuals aged 20 years and older in family medicine outpatient clinics. A questionnaire consisting of 30 questions was applied to 300 people who volunteered to participate in the study by a face-to-face interview. Results: Of all participants, 70% had not heard of advance directives (ADs) before this survey. Three quarters of participants thought that advanced directives were necessary. The rate of requesting cardiopulmonary resuscitation (CPR) to prolong survival in the case of end-of-life care was 55%; the rate of requesting the continuation of life-sustaining treatment was 24%. Conclusion: Most participants want their own decision to be taken into account in end-of-life care. Family physicians should talk to their patients about ADs via effective communication when people are still healthy.
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Buiar PG, Goldim JR. Barriers to the composition and implementation of advance directives in oncology: a literature review. Ecancermedicalscience 2019; 13:974. [PMID: 31921345 PMCID: PMC6946425 DOI: 10.3332/ecancer.2019.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 12/21/2022] Open
Abstract
The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.
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Affiliation(s)
- Pedro Grachinski Buiar
- Medical Oncology Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0001-5144-1197
| | - José Roberto Goldim
- Bioethics Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0003-2127-6594
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Hamada S, Haruta J, Hamano J, Maeno T, Maeno T. Associated factors for discussing advance directives with family physicians by noncancer outpatients in Japan. J Gen Fam Med 2019; 20:82-92. [PMID: 31065472 PMCID: PMC6498101 DOI: 10.1002/jgf2.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/20/2019] [Accepted: 01/24/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Advance directives (ADs) are seldom discussed between primary care physicians (PCPs) and their patients, especially those with noncancer diseases. The aim was to identify the factors associated with discussing AD by noncancer patients with their physicians. METHODS This cross-sectional study was conducted in a hospital or clinic from October to December 2017. Physicians chose eligible noncancer patients aged 20 years or older to respond to an anonymous self-completed questionnaire inquiring about the objective variable "I want to discuss AD with my doctor," as well as basic characteristics, and facilitators and barriers to discussing AD identified in previous studies. The physicians responded to a survey comprising the Palliative Performance Scale (PPS) and inquiring about the disease category for each patient. Data were analyzed using binomial logistic regression analysis. RESULTS A total of 270 patients (valid response rate, 79.6%) were included. Multivariate analysis identified a period of visit to the study site ≥ 3 years (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.05-4.10), physicians who are very good at taking care of patients' disease (OR, 12.68; 95% CI, 1.12-143.22), and patients' worry about their quality of life (QOL) in the future (OR, 2.69; 95% CI, 1.30-5.57) as facilitators for discussing AD with physicians, and PPS ≤ 90 (OR, 0.51; 95% CI, 0.26-0.98) as a barrier. CONCLUSIONS Our study indicates that patients' future QOL concerns, a long period of visit to a hospital, and the presence of physical symptoms were associated with the willingness of noncancer patients to discuss AD with PCPs.
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Affiliation(s)
- Shuhei Hamada
- Graduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaJapan
| | - Junji Haruta
- Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Jun Hamano
- Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Takami Maeno
- Faculty of MedicineUniversity of TsukubaTsukubaJapan
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Fahner JC, Beunders AJ, van der Heide A, Rietjens JA, Vanderschuren MM, van Delden JJ, Kars MC. Interventions Guiding Advance Care Planning Conversations: A Systematic Review. J Am Med Dir Assoc 2019; 20:227-248. [DOI: 10.1016/j.jamda.2018.09.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
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Bellamy G, Stock J, Schofield P. Acceptability of Paper-Based Advance Care Planning (ACP) to Inform End-of-Life Care Provision for Community Dwelling Older Adults: A Qualitative Interview Study. Geriatrics (Basel) 2018; 3:geriatrics3040088. [PMID: 31011123 PMCID: PMC6371084 DOI: 10.3390/geriatrics3040088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/22/2018] [Accepted: 11/28/2018] [Indexed: 11/16/2022] Open
Abstract
This paper reports the findings from a study to investigate health care professionals’ views regarding the use and acceptability of two similar paper-based advance care planning (ACP) documents designed for older adults in their last year of life to inform end-of-life care provision. Participants’ views of using PEACE (Proactive Elderly Persons Advisory Care), a nurse led model with community geriatrician oversight, and PACe (proactive anticipatory care plan), a general practitioner (GP) led model implemented by two clinical commissioning groups (CCGs) as part of a wider pilot to determine their ability to improve end-of-life care provision, were explored. Hospital admission avoidance matrons took part in face to face interviews and care staff employed in private residential care homes took part in individual telephone interviews to explore their views of using the PEACE tool. Telephone interviews were conducted with GPs to explore their views of PACe. GPs and admission avoidance matrons were employed by CCGs and all study participants were recruited from the South East of England, where data collection took place in 2015. The data were analysed thematically. Findings from the study demonstrate how both tools provide a focus to ACP discussions to inform individual end-of-life care preferences. The importance of relationships was a pivotal theme established, trusting inter-professional relationships to enable multidisciplinary teamwork and a prior relationship with the older person (or their proxy in the case of cognitive impairment) to enable such conversations in the first place. Both tools enabled participants to think critically and reflect on their own practice. Notwithstanding participants’ views to improve their layout, using a paper-based approach to deliver streamlined ACP and end-of-life care was a theme to emerge as a potential barrier, and highlighted problems with accessing paper-based documentation, accuracy and care co-ordination in the context of multidisciplinary team working. The value of technology in overcoming this barrier and underpinning ACP as a means to help simplify service provision, promote integrated professional practice and provide seamless care, was put forward as a way forward.
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Affiliation(s)
- Gary Bellamy
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford CM1 1SQ, UK.
| | - Jennifer Stock
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK.
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK.
| | - Patricia Schofield
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford CM1 1SQ, UK.
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Evans J, Ball L, Wicher C. Implementation of Medical Orders for Life-Sustaining Treatment. Clin J Oncol Nurs 2016; 20:74-8. [DOI: 10.1188/16.cjon.74-78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Jawa RS, Shapiro MJ, McCormack JE, Huang EC, Rutigliano DN, Vosswinkel JA. Preadmission Do Not Resuscitate advanced directive is associated with adverse outcomes following acute traumatic injury. Am J Surg 2015; 210:814-21. [PMID: 26116324 DOI: 10.1016/j.amjsurg.2015.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 04/17/2015] [Accepted: 04/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Do Not Resuscitate (DNR) orders have been associated with poor outcomes in surgical patients. There is limited literature on admitted trauma patients with advanced directives indicating DNR status before admission (preadmission DNR [PADNR]). METHODS A retrospective review of the trauma registry of a suburban county was carried out for admitted trauma patients with age ≥41 years, who were admitted between 2008 and 2013. RESULTS Of 7,937 admitted patients, 327 had a preadmission advanced directive indicating DNR. PADNR patients were significantly older (87 vs 69 years), with more frequent comorbidities, and were more often admitted after a fall (94.2% vs 65.8%). PADNR patients had a higher Injury Severity Score (14 vs 11). They also had significantly increased rates of pneumonia, sepsis, myocardial infarction, and death (33.6% vs 5.9%). On multivariate logistic regression, the presence of a preadmission advanced directive indicating DNR status was independently associated with a 5.2-fold increased odds of mortality. CONCLUSION An advanced directive indicating DNR is associated with adverse outcomes following trauma.
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Affiliation(s)
- Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA.
| | - Marc J Shapiro
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Jane E McCormack
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Daniel N Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Friis P, Førde R. Advance care planning discussions with geriatric patients. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:233-5. [PMID: 25668539 DOI: 10.4045/tidsskr.14.0175] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Advance care planning discussions are conversations with patients about future treatment to ensure that the patients' wishes are known if their decision-making capacity fails. Many doctors fear that such conversations represent a strain on patients. We wished to test systematic advance care planning discussions on an acute geriatric ward and to investigate how patients felt about such discussions. MATERIAL AND METHOD All patients who were admitted were continuously assessed with regard to their capacity for reflection on their future illness. An internationally tested tool was used as a basis for discussion with willing patients. RESULTS Of 96 patients who were assessed, a total of 34 were found to be unsuitable and four declined. Of the 58 interviewed, 54 wanted complete transparency of information and 47 wanted their families to participate when important information was to be imparted and crucial decisions on treatment were to be made. A total of 11 wanted no involvement of their families in these processes. All of them wanted their doctor to participate in important decisions. The majority took a very positive view of an advance care planning discussion of this type. Only one had a negative attitude. INTERPRETATION The patients were overwhelmingly positive with regard to advance care planning discussions. They have important messages to convey about information, the involvement of their families and the intensity of end-of-life treatment.
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Affiliation(s)
- Pål Friis
- Medisinsk avdeling Sørlandet sykehus Kristiansand
| | - Reidun Førde
- Senter for medisinsk etikk Institutt for helse og samfunn Universitetet i Oslo
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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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Abstract
PURPOSE OF REVIEW To review the definition of advanced directive, understand the implications for the patient, family and healthcare team, and address the obstacles involved in the implementation. RECENT FINDINGS Advanced directives propose a model of healthcare based on patient preferences. Although there is sufficient evidence related to their usefulness, various factors are known to affect the use of advanced directives. Therefore, rules need to be established in order to optimize the implementation process. SUMMARY An advanced directive is a legal document based on the principle of autonomy that expresses the desire of the patient in relation to different medical treatments when the patient is unable to make those decisions. The advanced directives are represented in three formats: Living Will, Appointment of a Healthcare Proxy and Legal Status of Preferences. The uses of advanced directives have an impact not only on the patients and their families, but also on the healthcare team. Despite their utility being well known, there are several general barriers that affect implementation, as well as factors related to characteristics of each study population.
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Kossman DA. Prevalence, Views, and Impact of Advance Directives Among Older Adults. J Gerontol Nurs 2014; 40:44-50. [DOI: 10.3928/00989134-20140310-01] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 12/18/2013] [Indexed: 11/20/2022]
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Yancu CN, Farmer DF, Graves MJ, Rhinehardt A, Leahman D. Accepting Transitions. Am J Hosp Palliat Care 2014; 32:380-7. [DOI: 10.1177/1049909114528567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: African Americans typically underuse hospice care; this study explores their end of life attitudes. Methods: An iterative focus group strategy generated qualitative data using 4 baseline groups and 1 confirmatory focus group recruited from predominantly African American churches. Each group consisted of 8 to 14 adults. Investigators analyzed data for dominant themes, representatives from baseline groups returned to discuss the results. Results: A total of 43 African Americans (male: 8 [18.6]; female: 35 [81.4]) participated in initial discussions, with 10 returning for follow-up. The prevailing theme was transitions; with life to death dominating discourse; other themes included curative to palliative care and acceptance of death as inevitable. Recommendation: Among African Americans, outreach efforts may be strengthened by reframing the dying process as the product of many transitions and reaching out to faith-based communities.
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Affiliation(s)
- Cecile N. Yancu
- Department of Behavioral Sciences and Social Work, Winston-Salem State University, Winston-Salem, NC, USA
| | - Deborah F. Farmer
- Department of Behavioral Sciences and Social Work, Winston-Salem State University, Winston-Salem, NC, USA
| | - Mara J. Graves
- Department of Behavioral Sciences and Social Work, Winston-Salem State University, Winston-Salem, NC, USA
| | - April Rhinehardt
- Department of Student Affairs, Shaw University, Raleigh, NC, USA
| | - Dee Leahman
- Department of Community Education, Hospice & Palliative Care Center, Winston-Salem, NC, USA
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Trivedi S. Physician perspectives on resuscitation status and DNR order in elderly cancer patients. Rep Pract Oncol Radiother 2013; 18:53-6. [PMID: 24381748 DOI: 10.1016/j.rpor.2012.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 11/07/2012] [Accepted: 12/19/2012] [Indexed: 12/21/2022] Open
Abstract
AIM To evaluate the process of placing DNR order in elderly cancer patients in practice and analysis of physician perspectives on the issue. BACKGROUND Decision not to resuscitate (DNR/DNAR) is part of practice in elderly cancer care. Physicians issue such orders when a patient is suffering from irreversible disease and the patient's life is coming to an end. Modern practice emphasises the need of communication with the patients and their relatives while issuing a DNR. The decision making process of placing DNR can be quite daunting. The moral and ethical dimensions surrounding such a decision make it a contentious topic. MATERIALS AND METHODS We searched the literature to find relevant works that would help physicians and especially the junior health care staff in dealing with the complexities. In this article, we discuss the issues that physicians encounter whilst dealing with a DNR order in elderly cancer patients. RESULTS There are no objective adjuncts or guidelines directed towards the approach of placing a DNR in elderly cancer patients. Better communication with the patients and relatives when making such decision remains a very important aspect of a DNR decision. Most health care staff find themselves ill equipped to deal with such situation. Active training and briefing of junior staff would help them deal better with the stresses involved in this process. CONCLUSION There are complex psychosocial, medical, ethical and emotive aspects associated with placing a DNR order. Patients and their loved ones and the junior staff involved in the care of patient need early communication and briefing for better acceptance of DNR. Studies that could devise or identify tools or recommendations would be welcome.
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Weidemann EJ. The Ethics of Life and Death: Advance Directives and End-of-Life Decision Making in Persons with Dementia. JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE 2012. [DOI: 10.1080/15228932.2012.629591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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