Clinicians’ Attitudes Towards Do-Not-Resuscitate Directives in a Teaching Hospital in Saudi Arabia

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Abstract

The Do-Not-Resuscitate (DNR) directive has provided a major leap in end-of-life care. To demonstrate the factors influencing physicians’ DNR decisions in King Fahd University Hospital in the Eastern Province of Saudi Arabia, 42 physicians from the medical and surgical departments of the same center were requested to participate in a cross-sectional survey.

Thirty-six questionnaires were completed and returned from a total of 42 distributed among physicians, making a response rate of 85.7%. Certain diagnostic categories increase the likelihood of issuing a DNR order for a patient. Neurological (58.3%) and cardiovascular (41.7%) diseases were the highest response among other diseases in influencing physicians’ decisions. In addition, other factors like lack of comorbidities (55.5%), age (52.7%), and previous intensive care unit (ICU) admissions and resuscitation (44.4%) showed an effect on the directive decisions of DNR among investigated physicians. However, weak palliative care in the hospital (11.1%), religious beliefs (5.5%), and gender (2.7%) were the least associated factors affecting physicians’ DNR decisions.

This study addresses the influencing factors of DNR orders issuance among King Fahd Hospital of the University physicians. Physicians noted that cultural standards and religious beliefs do play a role in their decision-making but had less of an effect as compared to other clinical data such as comorbidities, age, and previous ICU admissions.

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Most cited references 16

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A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators.

(1995)

To improve end-of-life decision making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying. A 2-year prospective observational study (phase I) with 4301 patients followed by a 2-year controlled clinical trial (phase II) with 4804 patients and their physicians randomized by specialty group to the intervention group (n = 2652) or control group (n = 2152). Five teaching hospitals in the United States. A total of 9105 adults hospitalized with one or more of nine life-threatening diagnoses; an overall 6-month mortality rate of 47%. Physicians in the intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation (CPR), and functional disability at 2 months. A specifically trained nurse had multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication. The phase I observation documented shortcomings in communication, frequency of aggressive treatment, and the characteristics of hospital death: only 47% of physicians knew when their patients preferred to avoid CPR: 46% of do-not-resuscitate (DNR) orders were written within 2 days of death; 38% of patients who died spent at least 10 days in an intensive care unit (ICU); and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least half the time. During the phase II intervention, patients experienced no improvement in patient-physician communication (eg, 37% of control patients and 40% of intervention patients discussed CPR preferences) or in the five targeted outcomes, ie, incidence or timing of written DNR orders (adjusted ratio, 1.02; 95% confidence interval [CI], 0.90 to 1.15), physicians' knowledge of their patients' preferences not to be resuscitated (adjusted ratio, 1.22; 95% CI, 0.99 to 1.49), number of days spent in an ICU, receiving mechanical ventilation, or comatose before death (adjusted ratio, 0.97; 95% CI, 0.87 to 1.07), or level of reported pain (adjusted ratio, 1.15; 95% CI, 1.00 to 1.33). The intervention also did not reduce use of hospital resources (adjusted ratio, 1.05; 95% CI, 0.99 to 1.12). The phase I observation of SUPPORT confirmed substantial shortcomings in care for seriously ill hospitalized adults. The phase II intervention failed to improve care or patient outcomes. Enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices. To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measured may be needed.

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Identifying the palliative care needs of patients living with cerebral tumors and metastases: a retrospective analysis.

Teneille Gofton, Jerome Graber, Alan Carver (2012)

Primary tumors and metastatic involvement of the central nervous system (CNS) lead to a multitude of symptoms and care needs. Patients and caregivers struggle with physical and psychological impairments, a shortened life expectancy and diverse palliative care needs. This study assesses the symptom burden and palliative care needs of patients with primary brain tumors and with metastatic brain tumors requiring inpatient hospital care. It is a retrospective analysis of patients with primary CNS tumors or cerebral metastases over a 6 month period. The data analysed included physical symptom burden and end of life care decisions such as health care proxy, transition to hospice and do-not-resuscitate orders. Hundred and sixty eight patients were included. The most common symptoms were gait impairment (65.5 %), cognitive/personality change (61.9 %), motor deficits (58.3 %), seizures (57.1 %) and delirium (27.4 %). Of the patients that died, 79 % had an appointed health care proxy, 79 % had hospice discussions, 70 % had a do-not-resuscitate order and 24 % received cancer directed therapy in the last month of life. There is a role for more aggressive palliative care support in patients living with primary or metastatic brain tumors.

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Do-not-resuscitate order: a view throughout the world.

Cristina Santonocito, Giuseppe Ristagno, Antonino Gullo … (2013)

Resuscitation has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort, and consume resources. The do-not-resuscitate (DNR) order and advance directives are still a debated issue in critical care. This review will focus on several aspects, regarding withholding and/or withdrawing therapies and advance directives in different continents. It is widely known that there is a great diversity of cultural and religious beliefs in society, and therefore, some critical ethical and legal issues have still to be solved. To achieve a consensus, we believe in the priority of continuing education and training programs for health care professionals. It is our opinion that a serious reflection on ethical values and principles would be useful to understand the definition of medical professionalism to make it possible to undertake the best way to avoid futile and aggressive care. There is evidence of the lack of DNR order policy worldwide. Therefore, it appears clear that there is a need for standardization. To improve the attitude about the DNR order, it is necessary to achieve several goals such as: increased communication, consensus on law, increased trust among patients and health care systems, and improved standards and quality of care to respect the patient's will and the family's role.

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Author and article information

Journal

Journal ID (nlm-ta): Cureus

Journal ID (iso-abbrev): Cureus

Journal ID (issn): 2168-8184

Title: Cureus

Publisher: Cureus (Palo Alto (CA) )

ISSN (Electronic): 2168-8184

Publication date (Electronic, pub): 30 December 2019

Publication date (Electronic, collection): December 2019

Volume: 11

Issue: 12

Electronic Location Identifier: e6510

Affiliations

[1 ] Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU

[2 ] Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU

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Gada M. Alsaffar gmsaffar@ 123456gmail.com

Article

DOI: 10.7759/cureus.6510

PMC ID: 6937465

PubMed ID: 31903316

SO-VID: 8d4eadd3-8a2a-492c-ab6f-f3c81a6714b7

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Clinicians’ Attitudes Towards Do-Not-Resuscitate Directives in a Teaching Hospital in Saudi Arabia

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Thermal Imaging in Social Decision Making

Most cited references 16

A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators.

Identifying the palliative care needs of patients living with cerebral tumors and metastases: a retrospective analysis.

Do-not-resuscitate order: a view throughout the world.

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