Clinical ethics

The practicalities of terminally ill patients signing their own DNR orders—a study in Taiwan

¹ Department of Community and Family Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
² School of Nursing College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
³ Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan

Correspondence to:
Dr T-Y Chiu, Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, No. 7, Chuang-Shan South Road, Taipei, 100 Taiwan; tychiu{at}ha.mc.ntu.edu.tw

Objectives: To investigate the current situation of completing the informed consent for do-not-resuscitate (DNR) orders among the competent patients with terminal illness and the ethical dilemmas related to it.

Participants: This study enrolled 152 competent patients with terminal cancer, who were involved in the initial consultations for hospice care.

Analysis: Comparisons of means, analyses of variance, Student’s t test, ² test and multiple logistic regression models.

Results: After the consultations, 117 (77.0%) of the 152 patients provided informed consent for hospice care and DNR orders. These included 21 patients (17.9%) who signed the consent by themselves, and 96 (82.1%) whose consent sheet was signed only by family members. The reasons why patients were not involved in the discussions toward the consent (n = 82) included poor physical or psychological condition (44.9%), concerns of the consultant hospice team (37.2%), and the family’s refusal (28.2%). On a multivariate analysis, patients’ awareness of their poor prognosis (odds ratio = 4.07, 95% confidence interval = 2.05 to 8.07) and their understanding of hospice care (2.27, 1.33 to 3.89) were two independent factors (p<0.01) that influenced their participation in the discussions or their personal signature in the informed consent.

Conclusion: The family-oriented culture in Asian countries may violate the principles of the Patient Self-Determination Act and the requirements of the Hospice Care Law in Taiwan, which inevitably poses an ethical dilemma. Earlier truth-telling and continuing education of the public by hospice care workers will be helpful in solving such ethical dilemmas.

Keywords: hospice care law; ethical dilemma; informed consent; terminal cancer patient; competency

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