Impediments to Writing Do-Not-Resuscitate Orders

Abstract

Limitations in the extent and depth of the physician-patient relationship appear to be the most frequent impediments to writing DNR orders in our institution.

Patients' characteristics associated with the decision of “do not attempt cardiopulmonary resuscitation” order in a Swiss hospital

“…The frequency of DNACPR orders established within the 72 h after admission was 53%, which is higher than the data previously documented in the scientific literature (8.6-24% and even 40% in a nursing home) [6][7][8][12][13][14][15]. Only 39% of these decisions involved the patients and/or their relatives.…”

“…Numerous publications exist about the difficulties encountered by a medical team faced with the DNACPR order [7,8]. In Switzerland, the first directives were published in 2008 and reviewed in 2013 to conform with changes in Swiss legislation, where more autonomy is given to the patient's legal representative, when the patient is unable to make a decision [9].…”

“…Previous studies documented that the rate of DNACPR order among patients is variable: 8.6 to 24% for hospitalized patients [6][7][8][12][13][14][15] and up to 40% in nursing homes [16]. Several factors are associated with the DNACPR order: older age [7,12,16,17], presence of several comorbidities [12,[17][18][19], oncologic status [7,12,19], psychiatric disease [7], poor quality of life [7,17] and poor prognostic [7,17].…”

Should There be a Choice for Cardiopulmonary Resuscitation When Death is Expected? Revisiting an Old Idea Whose Time is Yet to Come

“…18 A DNR order is unique because unlike other orders, CPR is done without an explicit doctor's order 34 or the patient's consent. 1-3,7,8,14-17, [24][25][26][27][28]35 According to the 1994 ACLS textbook, 1 DNR means: "In the event of an acute cardiac arrest, no CPR measures will be instituted or continued." It was suggested that the terms "Do Not Attempt Resuscitation" (DNAR) or "No CPR" are more appropriate because the term "do-not-resuscitate" suggests that a person could be resuscitated if CPR were performed.…”

“…Despite this, the presumption of resuscitation and the practice of attempting CPR on all hospitalized patients regardless of the underlying disease process persists unless there is consent from the patient or surrogate decision maker for a do-not-resuscitate (DNR) order. 1,2,4,[6][7][8][9][10][11][12][13][14][15][16][17]21,22,[24][25][26][27][28] The choice for attempting CPR is inherently a consideration in all hospitalized patients whether or not the issue is addressed. If it is not addressed, a resuscitation effort will automatically occur by default if a patient has a cardiopulmonary arrest.…”