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J Med Ethics 39:158-165 doi:10.1136/medethics-2012-100699
  • Clinical ethics
  • Paper

Including patients in resuscitation decisions in Switzerland: from doing more to doing better

  1. Bernice Elger5
  1. 1Institute for Biomedical Ethics, Geneva University Medical School, Geneva, Switzerland
  2. 2General Internal Medicine Service, Geneva University Hospitals, Geneva, Switzerland
  3. 3Department of Primary Care and Community Medicine, Geneva University Hospitals, Geneva, Switzerland
  4. 4Oncology Service, Geneva University Hospitals, Geneva, Switzerland
  5. 5Center for Legal Medicine, Geneva University Medical School, Geneva, Switzerland
  1. Correspondence to Dr Samia A Hurst, Institute for Biomedical Ethics, Geneva University Medical School, CMU/1 rue Michel Servet, CH-1211 Genève 4, Geneva, Switzerland; samia.hurst{at}unige.ch
  • Received 27 March 2012
  • Revised 8 October 2012
  • Accepted 16 October 2012
  • Published Online First 8 November 2012

Abstract

Background Decisions regarding Cardio-Pulmonary Resuscitation (CPR) and Do Not Attempt Resuscitation (DNAR) orders remain demanding, as does including patients in the process.

Objectives To explore physicians’ justification for CPR/DNAR orders and decisions regarding patient inclusion, as well as their reports of how they initiated discussions with patients.

Methods We administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion.

Results Justifications were provided for 59% of DNAR orders and included severe comorbidity, patients and families’ resuscitation preferences, patients’ age, or poor prognosis or quality of life. Reasons to include patients in CPR/DNAR decisions were provided in 96% and 84% of cases, and were based on respect for autonomy, clinical assessment of the situation as not too severe, and the view that such inclusion was required. Reasons for not including patients were offered in 84% of cases for CPR and in 70% for DNAR. They included absent decision-making capacity, a clinical situation viewed as good (CPR) or offering little hope of recovery (DNAR), barriers to communication, or concern that discussions could be emotionally difficult or superfluous. Decisions made earlier in the patient's management were infrequently viewed as requiring revision. Residents reported a variety of introductions to discussions with patients.

Conclusions These results provide better understanding of reasons for CPR/DNAR decisions, reasons for patient inclusion or lack thereof, and ways in which such inclusion is initiated. They also point to potential side-effects of implementing CPR/DNAR recommendations without in-depth and practical training. This should be part of a regular audit and follow-up process for such recommendations.

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