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Chen RY, Li YC, Hsueh KC, Wang FW, Chen HJ, Huang TY. Factors influencing terminal cancer patients' autonomous DNR decision: a longitudinal statutory document and clinical database study. BMC Palliat Care 2022; 21:149. [PMID: 36028830 PMCID: PMC9419392 DOI: 10.1186/s12904-022-01037-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Much of our knowledge of patient autonomy of DNR (do-not-resuscitate) is derived from the cross-sectional questionnaire surveys. Using signatures on statutory documents and medical records, we analyzed longitudinal data to understand the fact of terminal cancer patients’ autonomous DNR decision-making in Taiwan. Methods Using the medical information system database of one public medical center in Taiwan, we identified hospitalized cancer patients who died between Jan. 2017 and Dec. 2018, collected their demographic and clinical course data and records of their statutory DNR document types, letter of intent (DNR-LOI) signed by the patient personally and the consent form signed by their close relatives. Results We identified 1,338 signed DNR documents, 754 (56.35%) being DNR-LOI. Many patients had the first DNR order within their last week of life (40.81%). Signing the DNR-LOI was positively associated with being under the care of a family medicine physician prior to death at last hospitalization and having hospice palliative care and negatively associated with patient age ≥ 65 years, no formal education, having ≥ 3 children, having the first DNR order to death ≤ 29 days, and the last admission in an intensive care unit. Conclusions A substantial proportion of terminal cancer patients did not sign DNR documents by themselves. It indicates they may not know their actual terminal conditions and lose the last chance to grasp time to express their life values and wishes. Medical staff involving cancer patient care may need further education on the legal and ethical issues revolving around patient autonomy and training on communicating end-of-life options with the patients. We suggest proactively discussing DNR decision issues with terminal cancer patients no later than when their estimated survival is close to 1 month.
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Affiliation(s)
- Ru-Yih Chen
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC.,Department of Business Management, Institute of Health Care Management, National Sun Yat-Sen University, No. 70. Lianhai Rd, Kaohsiung, Taiwan, ROC
| | - Ying-Chun Li
- Department of Business Management, Institute of Health Care Management, National Sun Yat-Sen University, No. 70. Lianhai Rd, Kaohsiung, Taiwan, ROC.
| | - Kuang-Chieh Hsueh
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Fu-Wei Wang
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Hong-Jhe Chen
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Tzu-Ya Huang
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
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Brown SES, Antiel RM, Blinman TA, Shaw S, Neuman MD, Feudtner C. Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital. J Pain Symptom Manage 2019; 57:971-979. [PMID: 30731168 DOI: 10.1016/j.jpainsymman.2019.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 02/05/2023]
Abstract
CONTEXT Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited. OBJECTIVES To evaluate perioperative management of DNR orders at a tertiary care children's hospital. METHODS We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period. RESULTS Twenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point. CONCLUSION Opportunities exist to improve how DNR orders are managed during the perioperative period.
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Affiliation(s)
- Sydney E S Brown
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Ryan M Antiel
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Thane A Blinman
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susanna Shaw
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark D Neuman
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA; Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Syed AA, Almas A, Naeem Q, Malik UF, Muhammad T. Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study. Palliat Med 2017; 31:147-157. [PMID: 27226151 DOI: 10.1177/0269216316650789] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient's autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown. AIM To determine the barriers and perceptions in discussion of code status by physicians. DESIGN Questionnaire-based cross-sectional study. SETTING AND PARTICIPANTS This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included. RESULTS A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians. CONCLUSION Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries.
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Affiliation(s)
- Ahsan A Syed
- 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Aysha Almas
- 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Quratulain Naeem
- 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Umer F Malik
- 2 Thomas J. Long School of Pharmacy & Health Sciences, University of the Pacific, Stockton, CA, USA
| | - Tariq Muhammad
- 1 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Osinski A, Vreugdenhil G, de Koning J, van der Hoeven JG. Do-not-resuscitate orders in cancer patients: a review of literature. Support Care Cancer 2017; 25:677-85. [PMID: 27771786 DOI: 10.1007/s00520-016-3459-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
Discussing do-not-resuscitate (DNR) orders is part of daily hospital practice in oncology departments. Several medical factors and patient characteristics are associated with issuing DNR orders in cancer patients. DNR orders are often placed late in the disease process. This may be a cause for disagreements between doctors and between doctors and patients and may cause for unnecessary treatments and admissions. In addition, DNR orders on itself may influence the rest of the medical treatment for patients. We present recommendations for discussing DNR orders and medical futility in practice through shared decision-making. Prospective studies are needed to investigate in which a patient's cardiopulmonary resuscitation (CPR) is futile and whether or not DNR orders influence the medical care of patients.
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Street M, Considine J. Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to Emergency Departments. ACTA ACUST UNITED AC 2015; 19:37-43. [PMID: 26601595 DOI: 10.1016/j.aenj.2015.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 09/24/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear. METHODS Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010. RESULTS Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%). CONCLUSIONS Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.
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Affiliation(s)
- Maryann Street
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety, Geelong, Victoria, Australia; Eastern Health - Deakin University Nursing & Midwifery Research Centre, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia.
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety, Geelong, Victoria, Australia; Eastern Health - Deakin University Nursing & Midwifery Research Centre, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia
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Abstract
BACKGROUND Data on deaths in the general wards of our hospital in 2007 revealed infrequent discussions on end-of-life care and excessive burdensome interventions. AIM A physician order form to withhold inappropriate life-sustaining interventions was initiated in 2009. The use of the form was facilitated by staff educational sessions and a palliative care consult service. This study aims to evaluate the impact of these interventions in 2010. DESIGN Retrospective medical chart review with comparisons was made for the following: baseline patient characteristics, orders concerning life-sustaining therapies, treatment provided in last 24 h of life, and discussion of specific life-sustaining therapies with patients and families. SETTINGS/PARTICIPANTS This study included all adult patients who died in our hospital's general wards in 2007 (N = 683) versus 2010 (N = 714). RESULTS There was an increase in orders to withhold life-sustaining therapies, such as cardiopulmonary resuscitation (66.2%-80.0%). There was a decrease in burdensome interventions such as antibiotics (44.9%-24.9%) and a small increase in palliative treatments such as analgesia (29.1%-36.7%). There were more discussions on the role of cardiopulmonary resuscitation with conversant patients (4.6%-10.2%) and families (56.5%-79.8%) (p-value all < 0.05). On multivariate analysis, the physician order form independently predicted orders to withhold cardiopulmonary resuscitation. CONCLUSIONS A multifaceted intervention of a physician order form, educational sessions, and palliative care consult service led to an improvement in documentation of end-of-life discussions and was associated with an increase in such discussions and less burdensome treatments. There were small improvements in the proportion of palliative treatments administered.
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Affiliation(s)
- Adeline Tan
- 1Department of Medicine, Alexandra Hospital (Jurong Health Services), Singapore
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