The do-not-resuscitate order: still too little too late

Article Abstract:

The combination of an aging population and technological advances in medicine have resulted in an increasing number of patients who may be kept alive despite serious illness, but with great effort and expense. Often the quality of life in the terminal stages of disease is sufficiently poor that the patient asks not to be resuscitated if cardiorespiratory arrest occurs. Numerous articles have dealt with the various ethical aspects of a do-not-resuscitate (DNR) order. Many feel that the physician cannot make decisions about the quality of life for his patient, and that discussions with patients about DNR orders should take place during the earlier stages of illness, so that the patient may participate in a calm discussion. Without early discussion, emotional pressures may come to bear upon family members, and the patient may not be able to participate. The records of 274 consecutive deaths at a Pennsylvania medical center were reviewed to determine various practical aspects of the DNR order and its effect on appropriate medical care. Of the 274 deaths, 171 (62 percent) had a DNR order. The patient was involved in the DNR order in only 26 percent of the cases. Almost half of all patients for whom a DNR order was written were admitted to the hospital with reduced mental status. The average time for writing the order was 3.3 days before death. Only 4 percent of the patients had a preexisting DNR order upon admission to the hospital. It is clear that in this institution a DNR order is written for the majority of chronically ill patients. However, the order is usually written close to the death of the patient, and the patient is usually excluded from participation in the decision. The decision to issue a DNR order seems to be rarely considered before the patient is admitted to the hospital. Early decisions and the direct involvement of the patient would seem to be in the best interests of patients receiving terminal care. (Consumer Summary produced by Reliance Medical Information, Inc.)

Ethical aspects, Medical ethics, Right to die

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Evaluation of patient, physician, nurse, and family attitudes toward do not resuscitate orders

Article Abstract:

Do not resuscitate (DNR) orders are instructions given by a physician to the medical staff indicating that no basic or advanced life support techniques should be used for certain patients in the event of a cardiopulmonary arrest. The attitudes toward resuscitation were evaluated by interviewing 97 competent patients classified as DNR, 60 physicians, 80 family members, 84 nurses, and 58 family members of incompetent DNR patients. Patients were mainly elderly widows with a malignant disorder; 66 percent of patients preferred that the decision to resuscitate be shared with a physician or family member. Thirty-nine patients were able to define a 'living will', and 59 patients felt it important to ask non-critically ill patients at the time of hospitalization whether they had a living will. Fifty-six patients had discussed resuscitation with their doctors, whereas 44 physicians had discussed it with their patients. Fifty-three patients felt that their doctors understood their wishes concerning resuscitation, but 65 patients wanted to be more involved in the decision making. Quality of life accounted for reasons not to resuscitate in 48 cases. Sixty-four patients did not consider discussion of resuscitation cruel and insensitive, although 18 physicians felt uncomfortable about discussing the subject with patients. It is suggested that resuscitation be discussed early in the physician-patient relationship before competency diminishes. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, Social policy, Living wills

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Informed consent for colonoscopy; a prospective study

Article Abstract:

Two important aspects in the relation between a physician and a patient are: the extent to which patients are informed about the nature and progression of their disease; and the role taken by patients in determining treatment. The 'autonomy' model in which patients are permitted to become extensively involved in their medical care, and the 'paternalistic' model, in which patients are less involved, represent opposite patterns of physicians' behavior. With informed consent physicians inform patients fully about the risks and benefits of a proposed treatment and allow patients to decide whether the treatment will be performed. Although informed consent has become widespread in medical practice, the extent to which patient autonomy or independence affects medical decisions is not clear. The procedure of informed consent was assessed by surveying 16 physicians and 102 of their patients who were to undergo colonoscopy, the examination of the upper portion of the rectum with a specialized optical instrument. The results revealed that patients wanted more guidance from their physicians, and physicians did not regard their patients as being autonomous or independent in deciding on whether to have a colonoscopy. This suggests that the paternalistic model of physician behavior continues to influence the relation between physicians and patients in decisions of whether to perform colonoscopy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, Case studies, Colonoscopy, Surveys, Patient education, Informed consent (Medical law), Informed consent

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