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Abstract
Following the introduction of do-not-resuscitate (DNR) orders in the 1970s, there was widespread misinterpretation of the term among healthcare professionals. In this brief report, we present findings from a survey of healthcare professionals. Our aim was to examine current understanding of the term do-not-attempt-resuscitate (DNAR), decision-making surrounding DNAR and awareness of current guidelines. The survey was distributed to doctors and nurses in a university teaching hospital and affiliated primary care physicians in Dublin via email and by hard copy at educational meetings from July to December 2014. A total of 519 completed the survey. The response rate in the hospital doctors group was 35.5% (187/527), 19.8% (292/1477) in the nurses group but 68.8% (150/218) in the specialist nurses group and 40% (40/100) in the primary care physician group.
Alarmingly, our results demonstrate that 26.8% of staff nurses and 30% of primary care physicians surveyed believed that a patient with a DNAR order could not receive any/at least one of a list of simple treatments including antibiotics, physiotherapy, intravenous fluids, pain relief, oxygen, nasogastric feeding or airway suctioning, which were higher percentages compared to the other hospital doctors and experienced nurses groups with statistically significant differences (p<0.001). Furthermore, a higher percentage of staff nurses (26.8%) and primary care physicians (22.5%) believed that a patient with a DNAR order could not be referred to hospital from home/a nursing home, when compared with other healthcare groups (p<0.001). Our findings highlight continued misunderstanding and over-interpretation of DNAR orders. Further collaboration and information is required for meaningful Advance Care Plans.
- end-of-life
- decision-making
- clinical ethics
- right to healthcare
- aged
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Background
Widespread misinterpretation of do-not-resuscitate (DNR) orders prevailed among healthcare professionals in the 1970s1 2. A number of studies demonstrated that there was little concordance in physician understanding of DNR orders, with some physicians extending DNR orders to other therapeutic interventions including the discontinuation of care and withholding of life-sustaining treatments.1 2 While this may be appropriate following assessment of the individual patient, a DNR order on its own only provides instructions about cardiopulmonary resuscitation (CPR) and should not be assumed to convey any other care wishes. Additional studies found that patients with DNR orders in hospitals and long-term care facilities received fewer life-prolonging treatments after adjusting for age, function and illness severity.3 4 The terms do-not-attempt-resuscitation (DNAR) or do-not-attempt-cardiopulmonary-resuscitation (DNACPR) are now used preferably to do-not-resuscitate term as they emphasise the uncertainty surrounding the success of resuscitation efforts. However, more recent studies have established that DNAR orders continue to be poorly understood and interpreted to mean that elements of care should be withheld.5 6 Doctors have also been observed to believe that DNAR orders negatively affect their patients’ care which may result in reluctance to use DNAR orders.5
The British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing set out clear principles to be applied in reaching a decision about resuscitation which must be made on an individual case-by-case basis.7 In the Republic of Ireland, the National Consent Policy 2013 provides a decision-making framework to facilitate advance discussion of personal preferences regarding CPR and DNAR orders.8 9 It defines DNAR as a written order stating that resuscitation should not be attempted if an individual suffers a cardiac or respiratory arrest. Advance care planning (ACP), which includes decisions about CPR, is an important part of good clinical care for those at risk of cardiorespiratory arrest and is preferable to decision-making after a medical emergency occurs.8 An advance care directive (ACD) can include written instructions regarding a patient’s resuscitation and care wishes. While ACP already exists in Ireland, a new Irish act passed in December 2015 seeks to legislate for legally binding ACDs in the Republic of Ireland for the first time. Our survey principally aims to examine current understanding of the term DNAR among doctors and nurses in a university teaching hospital and affiliated primary care physicians in the community.
Methods
From July to December 2014, all doctors and nurses working within St. James’s Hospital, a large urban university hospital in Dublin, and affiliated primary care physicians were invited to complete an anonymous online survey via email and by hard copy distributed at educational meetings. Participant consent was obtained through agreement to complete the survey online and through verbal consent at educational meetings.
This is a mixed-methods study with integration of quantitative and qualitative methods within a single questionnaire (see online supplementary questionnaire). Surveys were managed using Google Forms online survey tool and Microsoft Excel. Analyses were carried out using Stata V.12.1. Continuous data are presented as means and SD, and categorical data are presented as frequencies and percentages. Differences in characteristics and survey responses between the groups of healthcare professionals were explored using Χ2 tests for categorical data and one-way analysis of variance and Kruskal-Wallis tests for continuous data. Evidence of a statistically significant difference between groups was set at p<0.05.
Supplementary file 1
Incomplete questionnaires (n=16) and questionnaires completed by students (n=2) were excluded.
Results
A total of 519 completed the survey (n=519); 69 (13.3%) consultants/attendings, 118 (22.7%) non-consultant hospital doctors, 150 (28.9%) specialist nurses, 142 (27.4%) staff nurses and 40 (7.7%) primary care physicians. The mean number of years of experience was 15.4 years. Characteristics of the healthcare professional groups and their specialties are presented in the online supplementary table 1. We have previously published an abstract on the below research findings (https://academic.oup.com/ageing/articlelookup/doi/10.1093/ageing/afw159.179).
Supplementary file 2
Response rates
The response rate in the hospital doctors group was 35.5% (187/527), 19.8% (292/1477) in the nurses group but 68.8% (150/218) in the specialist nurses group and 40% (40/100) in the primary care physician group.
Understanding of DNAR
Almost all participants (97.3%) identified the correct definition of DNAR in the survey. Subsequently, participants were asked whether a DNAR order precludes patients from receiving specific treatments. In the setting of a DNAR order, 26.8% of staff nurses and 30% of primary care physicians believed that a patient could not receive any or at least one of a list of less-invasive simple treatment options including antibiotics, physiotherapy, intravenous fluids, pain relief, oxygen, nasogastric feeding or airway suctioning. These were higher percentages compared with the other hospital doctors and experienced nurses groups with a statistically significant difference between groups (p<0.001). Between 18% and 32% of the healthcare groups believed that a patient could not receive more-invasive treatment options including chemotherapy, radiotherapy, dialysis or surgery if they had an existing DNAR with no statistically significant difference (p=0.12). A higher percentage of staff nurses (26.8%) and primary care physicians (22.5%) believed that a patient with a DNAR order could not be referred to hospital from home or a nursing home, when compared with the other healthcare groups (p<0.001). These results are shown in table 1 and as percentages of the total sample in online supplementary figure 1.
Supplementary file 3
Misconceptions regarding treatment limitations
Perceptions of the impact of DNAR orders on patient care
Over half of the sample (56.1%) felt that DNAR orders positively affect patient care, while 34.5% felt that they do not affect care and 9.4% felt they negatively affect care. Overestimation of cardiac arrest survival rates are presented in online supplementary table 2 and online supplementary figure 2.
Decision-making surrounding DNAR
We asked healthcare professionals ‘when they thought a DNAR order should be discussed/made in a patient with a life-limiting illness such as chronic obstructive pulmonary disease, advanced cancer or motor neuron disease’. There was a clear preference for discussion of DNAR following admission of the patient to hospital secondary to their life-limiting illness among all groups (p=0.42) (see online supplementary table 3 and online supplementary figure 3).
Preoperative discussion of patient wishes surrounding end-of-life was favoured by 72.8% of the sample as presented by specialty in online supplementary figure 4.
Supplementary file 8
Awareness of current guidelines
As many as 88.4% of participants have not read the National Consent Policy. Further training in DNAR orders was strongly supported by 96.3% of the total sample. Remaining responses to the survey are presented in online supplementary tables 4 and 5 .
Discussion
Our survey provides evidence of persistent misunderstanding of DNAR orders among healthcare professionals in Ireland since their introduction as confirmed in other English and American studies.5 6 While the term DNAR appears to be understood by the majority of doctors and nurses in theory, there appears to be marked misinterpretation of the term on a practical level with many believing it to pertain to the withholding of treatments. Over one-quarter of staff nurses and almost one-third of primary care physicians surveyed believe that a DNAR can preclude patients from receiving even elements of basic care. Alarmingly, over one in five primary care physicians surveyed believe that a patient with a DNAR order cannot be referred to hospital from home or a nursing home. This is particularly concerning given that primary care physicians are commonly tasked with deciding on whether to refer a patient to hospital or not and may be the only doctor to review the patient. This misinterpretation of DNAR orders among healthcare professionals has ethical implications for decision-making surrounding resuscitation, including resuscitation wishes as part of an ACD. Due to the risk of overinterpretation of DNAR orders to extend to other treatment decisions beyond resuscitation, it is clear that further information and collaboration is required for meaningful ACP.
Moreover, our findings highlight the need for further education in relation to DNAR orders in medical, primary care and nursing training programmes. However, the recent DNACPR evidence synthesis reported that studies into clinician education on DNACPR to date were limited in scope and did not provide compelling evidence that education in isolation improved clinical processes or patient outcomes.10 Nonetheless, it does recommend further research aimed at identifying effective training strategies to equip clinicians to make DNACPR decisions and improve their communication skills and awareness of the complexity surrounding these decisions.10 It also promoted a shift in focus from DNACPR orders alone to overall care and treatment plans.10
A number of tools have been developed to counteract misinterpretation of DNAR orders. Physician Orders for Life-Sustaining Treatment is a geriatric palliative care tool used in the USA that contains individualised medical orders conveying the patient’s treatment preferences when approaching end of life.11 It aims to ensure care plans on treatment decisions, and resuscitation status is documented in the patient’s medical record and honoured.12 13 Implementation of another tool, the Universal Form of Treatment Options (UFTO), demonstrated that an alternative approach that contextualised the resuscitation decision within an overall treatment plan resulted in positive patient outcomes14 and did not result in fewer intense nursing interventions.15 This form included clear instructions for review of the original UFTO decisions and indicated that it may be revoked in the context of a procedure that may induce cardiac arrest.14 Safeguards have also been recommended within the new Irish legislation and include time limits and automatic review of directives.16 17
Undoubtedly, this survey further highlights poor awareness of existing policy documents on DNAR among all healthcare professionals. This underscores the need for enhanced dissemination of important national policy documents such as the National Consent Policy.
The study has a number of limitations. Despite a relatively large sample size, the response rate for staff nurses was disappointing and likely due to their infrequent use of the hospital email service. However, our physician response rates are comparable to previously published physician survey-based studies.18 As with every survey, there may have been response bias and results may not be generalisable to other hospitals in Ireland or to other countries. The questionnaire was not validated or repeated. Nevertheless, this is the only published survey of the views of Irish doctors and nurses on resuscitation orders.
Conclusion
Our findings highlight continued misunderstanding and overinterpretation of DNAR orders. Further collaboration and information are required for meaningful ACPs.
Supplementary file 4
Supplementary file 5
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Supplementary file 7
Supplementary file 9
Supplementary file 10
References
Footnotes
Contributors HOB is the corresponding author and is responsible for the conception and design of the work; the acquisition, analysis and interpretation of the data; drafting the work and revising it critically for important intellectual content; gave final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of the work are appropriately investigated and resolved. SS specifically assisted in data coding, data management, data analysis and graphical presentation of results. AB was responsible for the conception and design of the work and data collection. KH assisted in data collection. RAK assisted in drafting the work and revising it critically for intellectual content. JM assisted in the conception and design of the work, analysis and interpretation of the data, drafting the work and revising it critically for important intellectual content.
Funding Financial support for this study was provided by Trinity College Dublin.
Competing interests None declared.
Ethics approval Tallaght, St. James’s Hospital Ethics Committee, and Nursing Research Access Committee
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Additional results are available as online supplementary material.