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

Abstract

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.

Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review

“…Although some doctors acknowledged the importance of remaining neutral, factual and non-influential when providing information [ 47 ] this was contrary to what was observed in practice. Conversation-framing bias was reported in eight studies [ 42 , 47 , 54 , 55 , 58 , 59 , 69 , 79 ] and was more common in situations where higher clinical uncertainty was present [ 69 ]. ‘Framing’ is a cognitive bias that relates to how a patient’s decision or thought process may be influenced by the way information is presented to them by their doctor.…”

“…Information provided by doctors commonly focussed more on medical or procedural interventions and less on broader life values [ 42 , 43 , 45 , 47 , 56 , 58 , 75 , 77 , 82 ]. Factors associated with this included the doctor’s perception that the patient was not at the end-of-life [ 67 , 76 ], when a medical intervention or surgical procedure was proposed [ 81 ], the perception by the doctor that quality of life was a “softer topic” [ 16 ], the perception that medical intervention was easier to communicate than personalised life goals [ 89 ].…”

“…Prior patient experience of hospital treatment and doctors checking understanding of any new information provided contributed to improved understanding [ 47 ]. Although doctors acknowledged the importance of patient understanding and recognised patients’ expectations, wishes and values [ 47 ], these were inconsistently explored and patients did not always feel empowered to speak up or own up in the event of a lack of understanding [ 42 ]. This resulted in patients being less informed [ 42 ].…”

“…However, this was not always identified by their doctors who sometimes made efforts to speak with the patient when family members were not present [ 58 ]. Discordant views regarding treatment options also existed between patients and family members [ 47 ]. This occurred when patients and their families held different motives and priorities relating to what they viewed as desirable medical treatments and associated outcomes [ 43 , 75 , 85 ], for example, the family prioritising survival whilst underappreciating the trade-offs of physical and mental morbidity (e.g.…”

“…Appropriate interpersonal skills were also perceived as important. These included measures such as introducing themselves, addressing patients or surrogates by their name, being personable [ 47 , 72 ] and warm [ 61 , 85 ], being approachable [ 85 ], listening to and understanding patients’ queries and concerns [ 23 , 60 , 63 ], providing information in a clear and jargon-free manner [ 19 , 47 , 61 , 73 , 82 ], showing honesty [ 85 ], compassion [ 47 , 61 , 73 ] and treating patients with respect and dignity [ 16 ]. The inclusion of family members in discussions (with the approval of the patient) was also deemed important in certain situations [ 19 ].…”