Classic cases revisited: Mrs Janet Tracey, resuscitation and the importance of good communication

Szawarski, Piotr

doi:10.1177/1751143715569020

Cited by 4 publications

(4 citation statements)

References 20 publications

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“…In addition, circumstances may change that make it necessary to review the CPR/DNAR status with patient input. The second element is that decisions regarding whether it is “worthwhile” to resuscitate represent, in the majority of cases, a value judgement rather than a matter of physiological probability, therefore any decisions regarding patient involvement in their CPR/DNAR decision-making will also constitute a judgment based upon a particular set of values that may contradict those of the patient affected [ 32 ]. There is wide consensus that it is extremely problematic to define the concept of futility in a medical context [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Obstacles to patient inclusion in CPR/DNAR decisions and challenging conversations: A qualitative study with internal medicine physicians in Southern Switzerland

et al. 2023

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Despite cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) decisions are increasingly considered an essential component of hospital practice and patient inclusion in these conversations an ethical imperative in most cases, there is evidence that such discussions between physicians and patients/surrogate decision-makers (the person or people providing direction in decision making if a person is unable to make decisions about personal health care, e.g., family members or friends) are often inadequate, excessively delayed, or absent. We conducted a study to qualitatively explore physician-reported CPR/DNAR decision-making approaches and CPR/DNAR conversations with patients hospitalized in the internal medicine wards of the four main hospitals in Ticino, Southern Switzerland. We conducted four focus groups with 19 resident and staff physicians employed in the internal medicine unit of the four public hospitals in Ticino. Questions aimed to elicit participants’ specific experiences in deciding on and discussing CPR/DNAR with patients and their families, the stakeholders (ideally) involved in the discussion, and their responsibilities. We found that participants experienced two main tensions. On the one side, CPR/DNAR decisions were dominated by the belief that patient involvement is often pointless, even though participants favored a shared decision-making approach. On the other, despite aiming at a non-manipulative conversation, participants were aware that most CPR/DNAR conversations are characterized by a nudging communicative approach where the physician gently pushes patients towards his/her recommendation. Participants identified structural cause to the previous two tensions that go beyond the patient-physician relationship. CPR/DNAR decisions are examples of best interests assessments at the end of life. Such assessments represent value judgments that cannot be validly ascertained without patient input. CPR/DNAR conversations should be regarded as complex interventions that need to be thoroughly and regularly taught, in a manner similar to technical interventions.

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Section: Discussionmentioning

confidence: 99%

Obstacles to patient inclusion in CPR/DNAR decisions and challenging conversations: A qualitative study with internal medicine physicians in Southern Switzerland

et al. 2023

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“…There have been issues with DNACPR ‘orders’ being made in secret. We should not be practising in an era of ‘orders’ – unilateral and paternalistic decisions 7 – but in an age of shared decision-making around wider priorities and preferences.…”

Section: Inadequate Communicationmentioning

confidence: 99%

“…6 Perhaps the problem is that we are not very good at recognising dying or accepting death? 7 In 2012, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a review of inhospital cardiopulmonary arrest: 'Time to Intervene?' 8 The review found that 90% of admission case notes had no documentation of decisions about CPR status.…”

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confidence: 99%

Resuscitation resolutions

Bostock

2023

Journal of the Royal College of Physicians of Edinburgh

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“…End-of-life (EOL) decisions relate to treatment strategies as death approaches or seems inevitable, 1 and in the intensive care unit (ICU), nearly 70% of deaths are associated with an explicit EOL plan. 2 Typically, clinicians and families reach decisions on a 'best interests' basis, 3,4 and act as surrogate decision makers who make a 'substituted decision' for a patient based on assumptions about their needs and desires. EOL decisions are often framed by a legal context, for instance the UK's Mental Capacity Act, 5 which mandates the seeking of views concerning values, goals, desires and cultural beliefs of an individual who lacks capacity.…”

Section: Introductionmentioning

confidence: 99%

At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit

Reader

Dayal

Brett

2020

Journal of the Intensive Care Society

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Background Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care. Methods Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians ( n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care. Results We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making. Conclusions To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.

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Classic cases revisited: Mrs Janet Tracey, resuscitation and the importance of good communication

Cited by 4 publications

References 20 publications

Obstacles to patient inclusion in CPR/DNAR decisions and challenging conversations: A qualitative study with internal medicine physicians in Southern Switzerland

Obstacles to patient inclusion in CPR/DNAR decisions and challenging conversations: A qualitative study with internal medicine physicians in Southern Switzerland

Resuscitation resolutions

At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit

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