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Original article

Vol. 141 No. 0506 (2011)

Do not attempt resuscitation: the importance of consensual decisions

  • L Imhof
  • R Mahrer-Imhof
  • C Janisch
  • A Kesselring
  • Zenklusen Zürcher
DOI
https://doi.org/10.4414/smw.2011.13157
Cite this as:
Swiss Med Wkly. 2011;141:w13157
Published
31.01.2011

Summary

AIMS: To describe the involvement and input of physicians and nurses in cardiopulmonary resuscitation (CPR / do not attempt resuscitation (DNAR) decisions; to analyse decision patterns; and understand the practical implications.

DESIGN: A Qualitative Grounded Theory study using one-time open-ended interviews with 40 volunteer physicians and 52 nurses drawn from acute care wards with mixes of heterogeneous cases in seven different hospitals in German-speaking Switzerland.

RESULTS: Establishing DNAR orders in the best interests of patients was described as a challenging task requiring the leadership of senior physicians and nurses. Implicit decisions in favour of CPR predominated at the beginning of hospitalisation; depending on the context, they were relieved/superseded by explicit DNAR decisions. Explicit decisions were the result of hierarchical medical expertise, of multilateral interdisciplinary expertise, of patient autonomy and/or of negotiated patient autonomy. Each type of decision, implicit or explicit, potentially represented a team consensus. Non-consensual decisions were prone to precipitate personal or team conflicts, and, occasionally, led to non-compliance.

CONCLUSION: Establishing DNAR orders is a demanding task. Reaching a consensus is of crucial importance in guaranteeing teamwork and good patient care. Communication and negotiation skills, professional and personal life experience and empathy for patients and colleagues are pivotal. Therefore, leadership by experienced senior physicians and nurses is needed and great efforts should be made with regard to multidisciplinary education.

References

  1. Aune S, Herlitz J, Bang A. Characteristics of patients who die in hospital with no attempt at resuscitation. Resuscitation. 2005;65(3):291–9.
  2. van Delden JJ, et al. Do-not-resuscitate decisions in six European countries. Crit Care Med. 2006;34(6):1686–90.
  3. Vetsch G, Uehlinger DE, Zuercher-Zenklusen RM. DNR orders at a tertiary care hospital – are they appropriate? Swiss Med Wkly. 2002;132(15–16):190–6.
  4. Chevrolet J. L’ordre “not to be resuscitated” (NTBR) chez l’adulte et chez l’enfant et Avis du Conseil d’éthique clinique des HUG. Médecine&Hygiène. 2003: p. 775–85.
  5. Hofmann JC, et al. Patient Preferences for Communication with Physicians about End-of-Life Decisions. Ann Intern Med. 1997;127:1–12.
  6. Levin JR, et al. Life-sustaining treatment decisions for nursing home residents: who discusses, who decides and what is decided? J Am Geriatr Soc. 1999;47(1):82–7.
  7. Meisel A, Snyder L, Quill T. Seven legal barriers to end-of-life care: myths, realities, and grains of truth. JAMA. 2000;284(19):2495–501.
  8. Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives. An empiric investigation of potential barriers. Arch Intern Med. 1994;154(20):2311–8.
  9. Richter J, Eisemann MR. Attitudinal patterns determining decision-making in the treatment of the elderly: a comparison between physicians and nurses in Germany and Sweden. Intensiv Care Med. 2000;26(9):1326–33.
  10. American Heart Association and International Liaison Committee on Resuscitation, Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care: An international consensus on science. Resuscitation. 2000;46:3–430.
  11. British Medical Association, Royal College of Nursing, and Resuscitation Council (UK) (2007) Decision relating to cardiopulmonary resuscitation. A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing.
  12. Schweizerische Akademie der Medizinischen Wissenschaften, Reanimationsentscheidungen. Medizinisch-ethische Richtlinien und Empfehlungen. 2008, SAMW: Basel.
  13. Burns JP, et al. Do-not-resuscitate order after 25 years. Crit Care Med. 2003;31(5):1543–50.
  14. De Gendt C, et al. Do-not-resuscitate policy on acute geriatric wards in Flanders, Belgium. J Am Geriatr Soc. 2005;53(12):2221–6.
  15. Ebrahim S. Do not resuscitate decisions: flogging dead horses or a dignified death? Resuscitation should not be withheld from elderly people without discussion. BMJ. 2000;320(7243):1155–6.
  16. Junod Perron N, Morabia A, A. de Torrente. Quality of life of Do-Not-Resuscitate (DNR) patients: how good are physicians in assessing DNR patients’ quality of life? Swiss Med Wkly. 2002;132(39–40):562–5.
  17. Ebell MH, et al. Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis. J Gen Intern Med. 1998;13(12):805–16.
  18. Eliasson AH, et al. Do-not-resuscitate decisions in the medical ICU: comparing physician and nurse opinions. Chest. 1997;111(4):1106–11.
  19. Layde PM, et al. Surrogates’ Predictions of Seriously ill Patients’ Resuscitation Preferences. Arch Fam Med. 1995;4:518–24.
  20. Phillips RS, et al. Choices of Seriously Ill Patients About Cardiopulmonary Resuscitation: Correlates and Outcomes. Am J Med. 1996;100:128–37.
  21. Seckler AB, et al. Substituted Judgment: How Accurate Are Proxy Predictions? Ann Intern Med. 1991;115:92–8.
  22. De Gendt C, et al. Nurses’ involvement in “do not resuscitate” decisions on acute elder care wards. J Adv Nurs. 2007;57(4):404–9.
  23. Strauss A. Qualitative analysis for social scientist. 1987, Cambridge: Cambridge University Press.
  24. Strauss A, Corbin JM. Basic of qualitative research: Techniques and procedures for developing Grounded Theory. 1998, Thousand Oaks, CA: Sage.
  25. Charmaz K. Constructing grounded Theory: A practical guide through qualitative analysis. 2006, London: SAGE.
  26. Clarke A. Situational analysis: Grounded theory after the postmodern turn. 2004, Thousand Oaks: SAGE.
  27. Robinson F, Cupples M, Corrigan M. Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study. Palliat Med. 2007;21(4):305–12.
  28. Naess M. “Do-Not-Attempt-Resuscitation”-orders in ICCUs: A survey of attitudes and experiences of nurses in Norway. Intensive Crit Care Nurs. 2008.
  29. Smith GB, Poplett N, Williams D. Staff awareness of a “Do Not Attempt Resuscitation” policy in a District General Hospital. Resuscitation, 2005;65(2):159–63.
  30. Holzapfel L, et al. A four-step protocol for limitation of treatment in terminal care. An observational study in 475 intensive care unit patients. Intensive Care Med. 2002;28(9):1309–15.
  31. Fields L. DNR does not mean no care. J Neurosci Nurs. 2007;39(5):294–6.
  32. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care. 2004;13(3):202–8.
  33. British Medical Association, The Recuscitation Council (UK), and Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation. A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. 2007 [cited 2008 December 26th]; Available from: http://www.bma.org.uk.
  34. Butler JV, et al. Improving decision-making and documentation relating to do not attempt resuscitation orders. Resuscitation. 2003;57(2):139–44.
  35. Giacomini MK, Cook DJ. Users’ guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence-Based Medicine Working Group. JAMA. 2000;284(4):478–82.
  36. Giacomini MK, Cook DJ. Users’ guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 2000;284(3):357–62.
  37. Mahrer R, Imhof L. Pflegegeschichten – Erfahrungslernen im pflegerischen Alltag, in Pflege lehren und lernen: Pädagogische und fachdidaktische Impulse zur Ausbildung im Gesundheitswesen, WE’G Weiterbildungszentrum für Gesundheitsberufe, Editor. 2004, h.e.p.: Bern. p. 53–63.
  38. Benner P, Tanner CA, Chesla CA. Expertise in nursing practice. 1996, New York: Springer.