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      Are physicians on the same page about do-not-resuscitate? To examine individual physicians’ influence on do-not-resuscitate decision-making: a retrospective and observational study

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          Abstract

          Background

          Individual physicians and physician-associated factors may influence patients’/surrogates’ autonomous decision-making, thus influencing the practice of do-not-resuscitate (DNR) orders. The objective of this study was to examine the influence of individual attending physicians on signing a DNR order.

          Methods

          This study was conducted in closed model, surgical intensive care units in a university-affiliated teaching hospital located in Northern Taiwan. The medical records of patients, admitted to the surgical intensive care units for the first time between June 1, 2011 and December 31, 2013 were reviewed and data collected. We used Kaplan–Meier survival curves with log-rank test and multivariate Cox proportional hazards models to compare the time from surgical intensive care unit admission to do-not-resuscitate orders written for patients for each individual physician. The outcome variable was the time from surgical ICU admission to signing a DNR order.

          Results

          We found that each individual attending physician’s likelihood of signing do-not-resuscitate orders for their patients was significantly different from each other. Some attending physicians were more likely to write do-not-resuscitate orders for their patients, and other attending physicians were less likely to do so.

          Conclusion

          Our study reported that individual attending physicians had influence on patients’/surrogates’ do-not-resuscitate decision-making. Future studies may be focused on examining the reasons associated with the difference of each individual physician in the likelihood of signing a do-not-resuscitate order.

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          Most cited references33

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          Understanding Power and Rules of Thumb for Determining Sample Sizes

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            Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada.

            To describe trends in the aggressiveness of end-of-life (EOL) cancer care in a universal health care system in Ontario, Canada, between 1993 and 2004, and to compare with findings reported in the United States. A population-based, retrospective, cohort study that used administrative data linked to registry data. Aggressiveness of EOL care was defined as the occurrence of at least one of the following indicators: last dose of chemotherapy received within 14 days of death; more than one emergency department (ED) visit within 30 days of death; more than one hospitalization within 30 days of death; or at least one intensive care unit (ICU) admission within 30 days of death. Among 227,161 patients, 22.4% experienced at least one incident of potentially aggressive EOL cancer care. Multivariable analyses showed that with each successive year, patients were significantly more likely to encounter some aggressive intervention (odds ratio, 1.01; 95% CI, 1.01 to 1.02). Multiple emergency department (ED) visits, ICU admissions, and chemotherapy use increased significantly over time, whereas multiple hospital admissions declined (P < .05). Patients were more likely to receive aggressive EOL care if they were men, were younger, lived in rural regions, had a higher level of comorbidity, or had breast, lung, or hematologic malignancies. Chemotherapy and ICU utilization were lower in Ontario than in the United States. Aggressiveness of cancer care near the EOL is increasing over time in Ontario, Canada, although overall rates were lower than in the United States. Health system characteristics and patient or physician cultural factors may play a role in the observed differences.
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              Physician factors associated with discussions about end-of-life care.

              Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss end-of-life issues. A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions. Among 4074 respondents, 65% would discuss prognosis "now" (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death "now" (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis "now" (P = .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death "now" (all P < .001). Most physicians report they would not discuss end-of-life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life.
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                Author and article information

                Contributors
                chen.yenyuan@gmail.com
                melanysu12@gmail.com
                cvshuang@gmail.com
                tschu@ntu.edu.tw
                linmt@ntu.edu.tw
                886-2-23123456 , clairrychun@gmail.com
                886-4-23323456 , okonkwolin@gmail.com
                Journal
                BMC Med Ethics
                BMC Med Ethics
                BMC Medical Ethics
                BioMed Central (London )
                1472-6939
                4 December 2019
                4 December 2019
                2019
                : 20
                : 92
                Affiliations
                [1 ]ISNI 0000 0004 0572 7815, GRID grid.412094.a, Department of Medical Education, Graduate Institute of Medical Education & Bioethics, , National Taiwan University College of Medicine, National Taiwan University Hospital, ; #1, Rd. Ren-Ai sec. 1, Chong-Cheng District, Taipei, 10051 Taiwan
                [2 ]ISNI 0000 0004 1936 8753, GRID grid.137628.9, New York University School of Medicine, ; #550 1st Avenue, New York, NY 10016 USA
                [3 ]ISNI 0000 0004 0572 7815, GRID grid.412094.a, Department of Surgery, , National Taiwan University Hospital, ; #7 Rd. Chong-Shan S, Taipei, 10002 Taiwan
                [4 ]ISNI 0000 0004 0546 0241, GRID grid.19188.39, Graduate Institute of Medical Education & Bioethics, , National Taiwan University College of Medicine, ; #1 Rd. Ren-Ai sec. 1, Chong-Cheng District, Taipei, 10051 Taiwan
                [5 ]ISNI 0000 0004 0546 0241, GRID grid.19188.39, Department of Surgery, , National Taiwan University College of Medicine, ; #1, Rd. Ren-Ai sec. 1, Chong-Cheng District, Taipei, 10051 Taiwan
                [6 ]ISNI 0000 0004 0572 7815, GRID grid.412094.a, Department of Medical Education, , National Taiwan University Hospital, ; #7, Rd. Chong-Shan S., Chong-Cheng District, Taipei, 10002 Taiwan
                [7 ]ISNI 0000 0000 9263 9645, GRID grid.252470.6, Department of Healthcare Administration, , Asia University, ; #500, Lioufeng Rd., Wufeng, Taichung, 41354 Taiwan
                Author information
                http://orcid.org/0000-0003-2047-6025
                Article
                429
                10.1186/s12910-019-0429-z
                6894148
                31801541
                67947359-9a43-40b5-baaa-4fe1fbfc9cc0
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 3 December 2018
                : 19 November 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100004663, Ministry of Science and Technology, Taiwan;
                Award ID: MOST 103-2511-S-002-008-MY5
                Award ID: MOST 108-2634-F-002-023
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100005762, National Taiwan University Hospital;
                Award ID: 105-N3316
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Medicine
                do-not-resuscitate,intensive care,decision-making
                Medicine
                do-not-resuscitate, intensive care, decision-making

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