A qualitative study of practice, culture and education of doctors in Sri Lanka regarding ‘do not attempt cardiopulmonary resuscitation’ decisions and disclosure

Abstract

Background: Doctors and the Sri Lanka Medical Association recognise the importance of do not attempt cardiopulmonary resuscitation decisions and disclosure; however, few previous studies exist examining these practices in Sri Lanka. Resuscitation decisions have seen significant changes in the UK in recent years, with a legal imperative for clear communication and a move to understand patients' preferred outcomes before recommending clinical guidance. Methods: Participants from two Sri Lankan hospitals were selected purposively to represent a range of specialties and seniorities for semi-structured interview. Results: Fifteen participants of varying seniorities were recruited. The practice of do not resuscitate decisions and informing patients is highly variable; there is no definitive guidance published on best practice of these issues in Sri Lanka. Participants felt that inpatients were generally not aware of their medical conditions or treatments. With the poor social and palliative care service provision in Sri Lanka comes a pressure to involve families in the patient care, particularly at the end of life. This feeds into a culture where patient autonomy plays a subordinate role to family involvement. Participants understand the ethical need for do not resuscitate decisions, however, it is viewed to be a consideration for when the patient is close to death. Conclusion: Do not resuscitate decisions do not appear to be a prominent feature of end-of-life care in Sri Lanka and thus consideration of the appropriateness of resuscitation is commonly left late in a patient's deterioration. Education, inclination and respect for doctors are suggested barriers to effective inclusion of patients in their healthcare and end-oflife decisions.

A Typical Perplexing Life-sustaining Therapy Decision at the End of life: A Case Report from Sri Lanka with Attributes Potentially worth Adopting from the UK Legislature

“…Patient's wishes playing a subordinate role to those of the colluding family members is a frequent obstacle to patient autonomy within the Sri Lankan cultural context. [6] e doctrine of 'double effect' legitimises acts aiming net benefit to the patient regardless of their unintended harms. [7] From a medical perspective, the overall 'survival to discharge rate' of CPR in metastatic cancer is 5.6%, [8] and the procedure entails a painful, unpleasant and possibly undignified terminal experience to the patient.…”