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      Translating into Practice Cancer Patients’ Views on Do-Not-Resuscitate Decision-Making

      1 , * , 2

      Cancers

      MDPI

      do-not resuscitate, advance care directive, cancer, DNR policy

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          Abstract

          Do-not-resuscitate (DNR) orders are necessary if resuscitation, the default option in hospitals, should be avoided because a patient is known to be dying and attempted resuscitation would be inappropriate. To avoid inappropriate resuscitation at night, if no DNR order has been recorded, after-hours medical staff are often asked to have a DNR discussion with patients whose condition is deteriorating, but with whom they are unfamiliar. Participants in two qualitative studies of cancer patients’ views on how to present DNR discussions recognized that such patients are at different stages of understanding of their situation and may not be ready for a DNR discussion; therefore, a one-policy-fits-all approach was thought to be inappropriate. To formulate a policy that incorporates the patient’s views, we propose that a standard form which mandates a DNR discussion is replaced by a “blank sheet” with instructions to record the progress of the discussion with the patient, and a medical recommendation for a DNR decision to guide the nursing staff in case of a cardiac arrest. Such an advance care directive would have to honor specifically expressed patient or guardian wishes whilst allowing for flexibility, yet would direct nurses or other staff so that they can avoid inappropriate cardiopulmonary resuscitation of a patient dying of cancer.

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          Most cited references 28

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          Using thematic analysis in psychology

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            Rhythms and outcomes of adult in-hospital cardiac arrest.

            To determine the relationship of electrocardiographic rhythm during cardiac arrest with survival outcomes. Prospective, observational study. Total of 411 hospitals in the National Registry of Cardiopulmonary Resuscitation. Total of 51,919 adult patients with pulseless cardiac arrests from April 1999 to July 2005. Registry data collected included first documented rhythm, patient demographics, pre-event data, event data, and survival and neurologic outcome data. Of 51,919 indexed cardiac arrests, first documented pulseless rhythm was ventricular tachycardia (VT) in 3810 (7%), ventricular fibrillation (VF) in 8718 (17%), pulseless electrical activity (PEA) in 19,262 (37%) and asystole 20,129 (39%). Subsequent VT/VF (that is, VT or VF occurring during resuscitation for PEA or asystole) occurred in 5154 (27%), with first documented rhythm of PEA and 4988 (25%) with asystole. Survival to hospital discharge rate was not different between those with first documented VF and VT (37% each, adjusted odds ratio [OR]) 1.08; 95% confidence interval [CI] 0.95-1.23). Survival to hospital discharge was slightly more likely after PEA than asystole (12% vs. 11%, adjusted OR 1.1; 95% CI 1.00-1.18), Survival to discharge was substantially more likely after first documented VT/VF than PEA/asystole (adjusted OR 1.68; 95% CI 1.55-1.82). Survival to discharge was also more likely after PEA/asystole without subsequent VT/VF compared with PEA/asystole with subsequent VT/VF (14% vs. 7% for PEA without vs. with subsequent VT/VF; 12% vs. 8% for asystole without vs. with subsequent VT/VF; adjusted OR 1.60; 95% CI, 1.44-1.80). Survival to hospital discharge was substantially more likely when the first documented rhythm was shockable rather than nonshockable, and slightly more likely after PEA than asystole. Survival to hospital discharge was less likely following PEA/asystole with subsequent VT/VF compared to PEA/asystole without subsequent VT/VF.
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              Difficult but necessary conversations--the case for advance care planning.

              Many patients at the end of life receive care that is inappropriate or futile and, if given the opportunity to discuss their care preferences well ahead of death, may well have chosen to forgo such care. Advance care planning (ACP) is a process of making decisions about future health care for patients in consultation with clinicians, family members and important others, and to safeguard such decisions if patients were to lose decisional capacity. Although ACP has existed as an idea for decades, acceptance and operationalisation of ACP within routine practice has been slow, despite evidence of its benefits. The chief barriers have been social and personal taboos about discussing the dying process, avoidance by medical professionals of responsibility for initiating, coordinating and documenting discussions about ACP, absence of robust and standardised procedures for recording and retrieving ACP documents across multiple care settings, and legal and ethical concerns about the validity of such documents. For ACP to become part of mainstream patient-centred care, accountable clinicians working in primary care, hospitals and nursing homes must effectively educate colleagues and patients about the purpose and mechanics of ACP, mandate ACP for all eligible patients, document ACP in accessible formats that enable patient wishes to accurately guide clinical management, devise methods for reviewing ACP decisions when clinically appropriate, and evaluate congruence between expressed patient wishes and actual care received. Public awareness campaigns coupled with implementation of ACP programs sponsored by collaborations between hospital and health services, Medicare locals and residential care facilities will be needed in making system-wide ACP a reality.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                Cancers (Basel)
                Cancers (Basel)
                cancers
                Cancers
                MDPI
                2072-6694
                27 September 2016
                October 2016
                : 8
                : 10
                Affiliations
                [1 ]Sansom Institute, University of South Australia, Adelaide 5000, Australia
                [2 ]School of Public Health, University of Adelaide, Adelaide 5000, Australia; jaklin.eliott@ 123456adelaide.edu.au
                Author notes
                [* ]Correspondence: ian.olver@ 123456unisa.edu.au ; Tel.: +61-40-922-0026
                Article
                cancers-08-00089
                10.3390/cancers8100089
                5082379
                27690104
                © 2016 by the authors; licensee MDPI, Basel, Switzerland.

                This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license ( http://creativecommons.org/licenses/by/4.0/).

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