Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it

Youngrye, Park; Kim, Jina; Kim, Kisook

doi:10.1177/0969733011410093

Cited by 25 publications

(50 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…This has raised the concern that at least some DNR patients might be medically or psychologically abandoned [9]. Although these studies did not specifically demonstrate abandonment, they may have reflected misinterpretation by or confusion of healthcare professionals about the proper level of medical care that should be provided to DNR patients [5][6][7][8]. Some healthcare professionals may have believed that DNR patients were eligible to receive medical interventions to extend life short of an arrest, while others thought that DNR was, essentially, an order for comfort care only.…”

Section: Introductionmentioning

confidence: 94%

See 1 more Smart Citation

Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching

et al. 2014

View full text Add to dashboard Cite

Background: Do-Not-Resuscitate (DNR) patients tend to receive less medical care after the order is written. To provide a clearer approach, the Ohio Department of Health adopted the Do-Not-Resuscitate law in 1998, indicating two distinct protocols of DNR orders that allow DNR patients to choose the medical care: DNR Comfort Care (DNRCC), implying DNRCC patients receive only comfort care after the order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), implying that DNRCC-Arrest patients are eligible to receive aggressive interventions until cardiac or respiratory arrest. The aim of this study was to examine the medical care provided to patients with these two distinct protocols of DNR orders. Methods: Data were collected from August 2002 to December 2005 at a medical intensive care unit in a university-affiliated teaching hospital. In total, 188 DNRCC-Arrest patients, 88 DNRCC patients, and 2,051 non-DNR patients were included. Propensity score matching using multivariate logistic regression was used to balance the confounding variables between the 188 DNRCC-Arrest and 2,051 non-DNR patients, and between the 88 DNRCC and 2,051 non-DNR patients. The daily cost of intensive care unit (ICU) stay, the daily cost of hospital stay, the daily discretionary cost of ICU stay, six aggressive interventions, and three comfort care measures were used to indicate the medical care patients received. The association of each continuous variable and categorical variable with having a DNR order written was analyzed using Student's t-test and the χ 2 test, respectively. The six aggressive interventions and three comfort care measures performed before and after the order was initiated were compared using McNemar's test. Results: DNRCC patients received significantly fewer aggressive interventions and more comfort care after the order was initiated. By contrast, for DNRCC-Arrest patients, the six aggressive interventions provided were not significantly decreased, but the three comfort care measures were significantly increased after the order was initiated. In addition, the three medical costs were not significantly different between DNRCC and non-DNR patients, or between DNRCC-Arrest and non-DNR patients. Conclusions: When medical care provided to DNR patients is clearly indicated, healthcare professionals will provide the medical care determined by patient/surrogate decision-makers and healthcare professionals, rather than blindly decreasing medical care.

show abstract

Section: Introductionmentioning

confidence: 94%

“…Nevertheless, several studies have shown that healthcare professionals tended to provide less medical care after DNR orders were written for patients [5][6][7][8]. This has raised the concern that at least some DNR patients might be medically or psychologically abandoned [9].…”

Section: Introductionmentioning

confidence: 99%

Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching

et al. 2014

View full text Add to dashboard Cite

show abstract

“…그러나 임상 현장에서 일부 의료인들은 DNR 을 치료를 하지 않는 것(Do not treat)으로 잘못 이해하 는 경향이 있다 (7). 일부 의사들은 DNR을 치료의 포기 로 간주하여 대부분의 치료를 줄이거나 소홀히 하고 (7,8), 간호사들 또한 DNR 환자에 대한 간호 행위를 줄 이거나 우선순위를 낮게 생각하는 경향이 있는 것이 사 실이다 (9). 그 이유는 의료진마다 DNR에 대한 해석과 태도에 혼란이 있음에도 불구하고 이를 바로잡아 줄 교 육이나 구체적 실무 지침이 없으며, 환자나 가족과의 적극적인 의사소통과 이를 통한 구체적 치료방향에 대한 의사결정 과정이 부족하기 때문이라고 할 수 있다 (7).…”

Section: 연구의 필요성unclassified

Changes of Nursing Activities on Patients with DNR Orders

Lee

Jang

2017

Korean J Hosp Palliat Care

View full text Add to dashboard Cite

Purpose:The purpose of this study is to identify the changes to nursing activities of nurses on patients with DNR (Do-Not-Resuscitate) order and factors associated to the changes. Methods: Data were collected using a structured questionnaire for 173 nurses at general hospitals. Logistic regression analysis was performed on the data using SAS 9.4. Results: With 39 nursing activities, an average of 60.4 (34.9%) nurses reported an increase in the activities, 102.4 (59.2%) no change and 10.1 (5.9%) a drop. The activity increase was the greatest in the social area, and the physical area was where the activities decreased the most. The activity increase was associated knowledge competency (9 items), attitudes (2 items), practical competency (4 items) and work load (14 items were). Conclusion: To offer systematical care for DNR patients, it is necessary to expand nurses' knowledge through end-of-life education and adjust their workload and provide a support system at the department level.

show abstract

“…reduced out-of-hours medical escalation, contacting the outreach team, frequency of nursing observations, reduced pain relief and altered fluid intake), despite clear guidelines that DNACPR orders applied only to CPR. Other examples of the misinterpretation of care for patients with DNACPR orders included where some doctors and nurses believed that nursing observations would be reduced 63,97 or remain unchanged, 100 that contact with outreach teams and other medical staff and out-of-hours medical escalation would be less frequent, although nurses less often felt that this occurred than doctors. 97 It was also suggested that pain relief and amounts of fluids would be altered 97 and one Finnish study 63 noted that basic care was reduced for patients with a DNACPR order.…”

Section: Treatment and Carementioning

confidence: 99%

“…Thirty-four articles are included here, 13,14,16,38,39,41,[63][64][65][67][68][69][70]73,75,76,[78][79][80][81][82][83][84]87,[89][90][91]93,95,97,98,[100][101][102] of which 18 are questionnaire or survey studies; six of these are high-quality studies, 69,70,78,93,95,102 one is of medium quality 38 and 11 are of low quality. [63][64][65]67,68,73,75,83,90,100,...…”

Section: Implementing the Decisionmentioning

confidence: 99%

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Perkins

Griffiths

George

et al. 2016

Health Serv Deliv Res

View full text Add to dashboard Cite

BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

show abstract

Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it

Cited by 25 publications

References 10 publications

Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching

Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching

Changes of Nursing Activities on Patients with DNR Orders

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Contact Info

Product

Resources

About