CPR decisions during hospital cardiac arrest – practice and opinions of physicians
*Paweł Andruszkiewicz, Andrzej Kański, Piotr Konopka
2nd Department of Anaesthesiology and Intensive Therapy, Warsaw Medical University
Background. DNAR is the procedure when CPR is not undertaken as it appears to conflict with the patient’s will or may not be in his or her best interests due to medical futility. DNAR decisions should be carefully discussed in advance by the medical team and patients and finally formally documented. DNAR orders are still extremely rare in Polish hospitals and decisions to forgo CPR are usually made at the very last moment. Therefore, we compare actual practice and opinions of physicians related to DNAR decisions.
Methods. The study, carried out during three consecutive months in a big university hospital, was based on two questionnaires. The first questionnaire explored actual practice regarding the decision to forgo CPR, whereas the second one - opinions about DNAR guidelines. The former was filled in by physicians involved in the “do not to attempt resuscitation” decision, the latter by the group of other physicians employed in the hospital.
Results. The survey was performed among 286 physicians filling in the first questionnaire and 200 physicians completing the second one. On-call doctors were prime decision makers (49%) with no input from the patient when the “do not attempt resuscitation” decision was made. Decisions to forgo resuscitation were usually informal and communicated to medical team orally (98%). However, 20% of physicians declare that patients should be involved in the decision-making process concerning CPR, and more then 30% respondents stress the need for collegial discussion. Nearly 80% of physicians believe that such formal decisions should be recorded in the patient’s medical history.
Conclusions. Current opinions of physicians regarding DNAR differ strikingly from clinical practice. Respondents highlighted the need for collegial discussions, the growing role of a patient in the decision-making process and importance of suitable documentation.
Everyday observations reveal that decisions about undertaking or withholding resuscitation in hospital cardiac arrest victims are made at the very last minute. Sometimes, life-sustaining actions are undertaken in situations which do not portend success or even without the patient`s consent. In Polish hospitals, „do not attempt resuscitation” (DNAR) decisions are rarely documented. In the past, similar situations happened in USA and European hospitals; due to well-known lawsuits and press scandals, some changes were introduced. Patients started to be involved in the process of decision-making concerning the way of treatment, including the extent of medical actions during cardiac arrest.
In our country, studies concerning the management strategies in such cases have not been conducted. Therefore, the objective of the study was to determine the currently applied rules that physicians base on while making the decisions regarding institution or withholding of resuscitation in cases of hospital cardiac arrest and to present the opinions of physicians about the rules that should be relevant for such decisions.
The questionnaire study was conducted during the three consecutive months in a large multi-profile teaching hospital after obtaining the approval of the Bioethics Committee of the Warsaw Medical University and the hospital authorities. The study consisted of two parts. The aim of the first questionnaire was to describe the currently applied rules of undertaking or withholding resuscitation in the hospital whereas the second questionnaire was to present opinions of physicians on the rules which should be applied.
The first questionnaire (Table 1) was completed ex post by physicians who were with their patients during cardiac arrest and decided to withhold resuscitation. The exclusion criteria were the cases in which contact with physicians pronouncing death failed, when cardiac arrest occurred in the admissions department or brain death was pronounced by the committee.
The second questionnaire was to reveal the opinions of physicians regarding the rules of instituting or withholding resuscitation.
Two hundred out of 500 physicians employed in the hospital were randomly chosen (random number tables). The study was voluntary and anonymous. The physicians included in the study received the questionnaire with the short information about the aim of the survey and instructions how to complete the questionnaires.
In the period analysed, 460 cases of cardiac arrest were noted; resuscitation procedures were instituted in 150 patients. Analysis involved medical records of 286 patients in whom resuscitation was withheld after cardiac arrest. Twenty-four cases were excluded due to methodological reasons.
According to the respondents, the decision to withhold resuscitation was made by four subjects: the physician on duty (one-man decision), the physician directly attending a patient (one-man decision), team of physicians, or the first two considered a team. Lack of answers taking into consideration the patient`s opinion is of much interest. The opinions to involve the patient`s family in decision making were sporadic (Table 3).
The question concerning the way the decision about withholding resuscitation is documented was answered by 284 respondents. The decision was most commonly passed orally (98.6%). Notes in the medical records were made in about 1.4% of cases. The separate documents were never prepared.
The patient`s will regarding the way and extent of medical treatment during cardiac arrest when resuscitation was withheld was known only in 7 cases (2.5%).
The answers to the question about who should make the decision about withholding resuscitation varied. The majority of respondents (over 28%) thought that such a decision should be made (in advance) by the team of physicians; for 18% of respondents the decision should be the patient`s and for 17% - it should be made by the doctor in-charge. According to the respondents, the nurses` opinions were of no relevance. Six respondents stated that nobody was authorized to make such decisions (Table 4).
Over half of 121 respondents thought that notes in the medical history were the main form of transmitting the information about forgoing resuscitation in some cases. Almost 20% believed that oral declaration was sufficient whereas 28% – that a separate DNAR document was required.
The DNAR idea was conceived in the USA 30 years ago. During the next years the idea was accepted by the largest medical associations . The most important elements of the DNAR procedure are to determine in advance the way and range of management in emergencies ( in this case cardiac arrest) and to substantiate formally the decision made.
In Poland, DNAR is still a taboo, reluctantly considered subject, by many physicians erroneously associated with euthanasia. On the other hand, in everyday hospital discussions, the lack of acceptance for undertaking resuscitation, e.g. in cases of agony in the terminal stage of neoplastic disease, is clearly articulated.
Analysis of questionnaire findings concerning the current practice of instituting or withholding resuscitation reveals an alarming picture. In up to 49% of cases the decisions about the way of management in hospital cardiac arrest victims are made by the physician on duty. The knowledge of hospital realities prompts that in many cases the knowledge of the physician on duty about the patient is too skimpy to make consciously one of the most difficult clinical decisions. Moreover, due to dramatic circumstances accompanying cardiac arrest this relevant decision is made during a few seconds. The questionnaire results indicate that the patient`s death is, to a large extent, the unexpected and surprising event for the therapeutic team.
The opinions of physicians markedly differ from the current practice. As far as the question who should make the DNR decision is concerned, the majority of respondents believe that this decision should be made by the team of physicians; according to some respondents, such a decision should be made by the physician on duty. The discrepancies between practices and beliefs how it should be are likely to evidence that physicians consider the current practice improper.
The rules applied in such cases are explicit. The collegial resuscitation-related decision making limits the risk of errors resulting from subjective assessment . One-man (physician on duty) decisions concerning withholding of resuscitation should not be accepted. There are countries, however, where medical paternalism predominates. In Portuguese intensive therapy units, DNAR decisions are made by the physician single-handed in 74% of cases, although only 43% of respondents assess this situation as proper . The majority of Israeli internists (73%) is willing to make DNAR decisions in incompetent patients without consulting other people and 55% could ignore the lack of patient`s consent for resuscitation . An extreme form of paternalism was observed amongst Archangelsk physicians; the questionnaire study carried out there disclosed that almost 2/3 of respondents considered the institution of resuscitation in the terminal stage of disease as proper ignoring the DNAR document, prognosis and the patient`s opinion they were aware of .
Another finding inclining to reflection is complete elimination of patients from discussions about their faith and the minimized role of their families. Such practices violate the right to autonomy and the rule of conscious consent to the way and range of therapy, which is included in the Polish Penal Code, the Act on the Physician Profession and the Code of Medical Ethics [6, 7]. The fact that some percentage of physicians recognizes such a need is slight consolation.
The role of a patient and his/her family in the process of determining the range of therapy in life threatening conditions varies with a country. In the USA, the autonomy of a patient is a priority; therefore, key decisions about treatment, including management in critical situations, are made with the patient involved. In Australia, over 80% of physicians and patients believe that the decision about instituting or withholding resuscitation should follow the discussion with both parties involved . Interestingly, the need to include the family in the decisive process is much rarely recognized (46%); only 23% of patients and 1% of physicians do not find the resuscitation-related conversations necessary . In Canada, the patient`s relatives are involved in making those difficult decisions in 94% of cases .
In Europe, the extent of medical management is more often discussed with the patient`s family (77%) than with the patient (26%). In each country, however, the situation looks slightly different. In France, in 44% of cases the decision about limitation of therapy is made with the families involved  while in Spain only in 28% of cases the opinions of families are ignored .
In Far East and India, medical paternalism predominates. In Japan and India, the decision about forgoing resuscitation is always consulted with the patient`s relatives and only in 5 % of cases with the patient [12, 13], which is explained by the traditional Far East belief about the necessity to protect the patient against “bad news”.
In Poland, the physicians do not consider nurses taking care of patients as partners and full members of the medical team; thus, their opinions on the way of treatment of severely ill patients are not taken into consideration; moreover, physicians do not see the need to change this practice. It seems that such a situation results from the organization of work in hospitals. Due to understaffing, each nurse attends too many patients and remains for them a strange and anonymous person; hence, there are no grounds to include her in such difficult discussions. On the other hand, in France, the nursing staff participates in 54% of decisions concerning limitation of therapy . In Portugal, 35% of physicians recognize the need to include nurses in the resuscitation decision-making teams . Similar opinions are expressed by 30% of Australian physicians and 36% of patients .
There were no cases in which bioethics committees were involved in the resuscitation-related decisions during cardiac arrest, nevertheless almost 10% of respondents felt such a need. This may result from the belief that decision about withholding resuscitation (when most likely futile) is of a medical rather than philosophical dimension. According to 45% of physicians from European intensive therapy units, ethical assessment would be helpful during making difficult decisions concerning the extent of therapy in critically ill patients. Such a need was more commonly expressed by Italian, Greek, Spanish and Portuguese physicians employed in smaller hospitals .
The results of our questionnaire study indicate that the will of patients about medical management during cardiac arrest is known only in single cases.
The findings show that in the majority of cases the DNAR information is informal and passed orally. Physicians participating in the study recognize the imperfection of this situation. More than 50% of respondents believe that the decision should be documented in the medical history; a high proportion states that a separate decision-related document is necessary.
In the USA, the physician is obliged to make a note in the medical records informing about the DNAR decision (or other forms of limited therapy) and to substantiate such a decision. Oral forms are unacceptable . Similar guidelines are applied in Great Britain; additionally, they oblige to pass DNAR orders to all members of the medical personnel attending the patient . The DNAR rules used in Scandinavian countries are properly defined [16, 17]. The European, multi-centre studies published in 1999 revealed that 58% of physicians documented the DNAR decisions by recording them in the medical histories (8% of Italian and 91% of Dutch physicians); more than 80% of respondents believe that the decisions must be written . A less optimistic picture is found in the studies carried out in 2004. Formal DNAR records are binding in 7 countries; in 4 countries, they are applied only in some hospitals and in 9 (including Poland) are not obligatory.
1. The DNAR decision is most often made by a physician on duty, whose knowledge about the patient`s will is incomplete. The role of patients in making such decisions is marginal.
2. In most cases, the decision to withhold resuscitation is conveyed informally and orally.
3. Physicians recognize the need to change the current practice of management.
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