Do Specialists Differ on Do-Not-Resuscitate Decisions?

doi:10.1378/chest.121.3.957

Chest

Volume 121, Issue 3, March 2002, Pages 957-963

https://doi.org/10.1378/chest.121.3.957 Get rights and content

Study objective

Opinions regarding do-not-resuscitate (DNR) decisions differ between individual physicians. We attempted to determine whether the strength of DNR recommendations varies with medical specialty and experience.

Design

Written survey.

Participants

Physicians from the pulmonary/critical-care medicine (PCCM), cardiology, internal medicine, gastroenterology, hematology/oncology, and infectious disease services as well as the Department of Medicine house staff at our tertiary-care referral center participated in the study.

Interventions

Physicians were asked confidentially to quantify the strength of their opinions on discussing and recommending DNR orders for each of 20 vignettes made from the summaries of actual cases. Reasons for their opinions and demographic data also were recorded.

Measurements and results

One hundred fifteen of 155 physicians (74%) responded. PCCM physicians (mean [± SD] DNR score, 157 ± 22) more strongly recommended DNR orders than cardiologists (mean DNR score, 122 ± 32; p = 0.006), house staff (mean DNR score, 132 ± 24; p = 0.014), and general internists (mean DNR score, 129 ± 30; p = 0.043). PCCM physicians also trended toward recommending DNR orders for more of the 20 patients described in the vignettes compared to cardiologists (mean DNR number, 16.5 ± 3.0 vs 11.9 ± 5.8, respectively; p = 0.066). There were no differences between PCCM physicians and hematology/oncology, infectious disease, and gastroenterology specialists. Among the house staff, the likelihood of recommending a DNR order correlated significantly with increasing years of experience (r = 0.45; p = 0.002). The opposite trend was present in the specialty staff groups. No significant differences in opinion by gender, religion, or personal experiences were found.

Conclusions

The strength of DNR order recommendations varies with medicine specialty and years of training and experience. An awareness of these differences and the determination of the reasons behind them may help to target educational interventions and to ensure effective collaboration with colleagues and communication with patients.

Section snippets

Materials and Methods

Physicians at our tertiary-care referral center were separated into the following seven groups: pulmonary and critical-care medicine (PCCM); cardiology; internal medicine; gastroenterology; hematology/oncology; infectious disease; and medicine house staff. All physicians in these groups were invited personally to confidentially complete the study questionnaire, which consisted of 20 clinical vignettes (see “^Appendix”). The vignettes were case summaries of patients who had been treated at our

Results

Of the 155 questionnaires distributed, 115 (74%) were returned. Table 1provides demographic information grouped by subspecialty. Blank answers to individual questions were rare (0.44%) and were excluded from the statistical analysis. There were no significant differences in physician ages within the various subspecialties. Groups were similar in terms of number of years of experience, with the exception of general internists who worked more years than did PCCM physicians. As may be expected,

Discussion

Our findings suggest that physicians in different internal medicine specialties, and with different levels of experience, vary in the strength of their recommendation of DNR orders. Willingness to limit care, specifically by recommending a DNR order, was statistically greater among PCCM physicians than among cardiologists, house staff, and general internists.

The clinical significance of such differences is unclear. When asked for an opinion, colleagues in different specialties often could agree

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Presented at the American Thoracic Society meeting, Toronto, Canada, May 5 to 10, 2000.

The authors are US government employees. The opinion or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of the Defense or any US government agency.

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Chest

Ethics in Cardiopulmonary MedicineDo Specialists Differ on Do-Not-Resuscitate Decisions?

Study objective

Design

Participants

Interventions

Measurements and results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Lancet

Patients’ and families’ preferences for medical intensive care

JAMA

Perceived quality of life and preferences for life-sustaining treatment in older adults

Arch Intern Med

Variability in physician bioethical decision-making

Ann Intern Med

Resuscitation: how do we decide? A prospective study of physicians’ preferences and the clinical course of hospitalized patients

JAMA

Advances in end-of-life care treatment planning: a research review

Arch Intern Med

A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognosis and preferences for outcomes and risks of treatments (SUPPORT)

JAMA

Impediments to writing do-not-resuscitate orders

Arch Intern Med

Who decides? Physicians’ willingness to use life-sustaining treatment

Arch Intern Med

Differences in attitudes toward terminal patients among selected medical specialties of physicians

Med Care

Ethics in Cardiopulmonary Medicine
Do Specialists Differ on Do-Not-Resuscitate Decisions?