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      Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision

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          As the do not resuscitate” (DNR) discussion involves communication, this study explored (1) the effects of a title that included “allow natural death”, and of information contents and outcomes of the decision; and (2) the information needs and consideration of the DNR decision, and benefits and barriers of the DNR discussion.


          Healthy adults ( n = 524) were presented with a scenario with different titles, information contents, and outcomes, and they rated the probability of a DNR decision. A questionnaire including information needs, consideration of the decision, and benefits and barriers of DNR discussion was also used.


          There was a significantly higher probability of signing the DNR order when the title included “allow natural death” ( t = − 4.51, p < 0.001), when comprehensive information was provided ( F = 60.64, p < 0.001), and when there were worse outcomes ( F = 292.16, p < 0.001). Common information needs included remaining life period and the prognosis. Common barriers were the families’ worries and uncertainty about future physical changes.


          The title, information contents, and outcomes may influence the DNR decisions. Health-care providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.

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          Most cited references 32

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          Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

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            The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.

            Studies suggest that a majority of elderly patients would want to undergo cardiopulmonary resuscitation (CPR) if they had a cardiac arrest. Yet few studies have examined their preferences after clinicians have informed them about the outcomes of CPR. To study older patients' preferences regarding CPR, we interviewed as many ambulatory patients as possible in one geriatrics practice in Denver from August 1, 1991, through July 31, 1992. A total of 371 patients at least 60 years of age were eligible; 287 completed the interview (mean age, 77 years; range, 60 to 99). When asked about their wishes if they had cardiac arrest during an acute illness, 41 percent opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (10 to 17 percent), 22 percent opted for CPR. Only 6 percent of patients 86 years of age or older opted for CPR under these conditions. When asked about a chronic illness in which the life expectancy was less than one year, 11 percent of the 287 patients opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (0 to 5 percent), 5 percent said they would want CPR. Older patients readily understand prognostic information, which influences their preferences with respect to CPR. Most do not want to undergo CPR once a clinician explains the probability of survival after the procedure.
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              Communication between physicians and family caregivers about care at the end of life: when do discussions occur and what is said?

              Few studies have examined physician-family caregiver communication at the end of life, despite the important role families have in end-of-life care decisions. We examined family caregiver reports of physician communication about incurable illness, life expectancy, and hospice; the timing of these discussions; and subsequent family understanding of these issues. Mixed methods study using a closed-ended survey of 206 family caregivers and open-ended, in-depth interviews with 12 additional family caregivers. Two hundred eighteen primary family caregivers of patients with cancer enrolled with hospice between October 1999 and June 2002. Family caregiver reports provided at the time of hospice enrollment of physician discussions of incurable illness, life expectancy, and hospice. Many family caregivers reported that a physician never told them the patient's illness could not be cured (20.8%), never provided life expectancy (40% of those reportedly told illness was incurable), and never discussed using hospice (32.2%). Caregivers reported the first discussion of the illness being incurable and of hospice as a possibility occurred within 1 month of the patient's death in many cases (23.5% and 41.1%, respectively). In open-ended interviews, however, family caregivers expressed ambivalence about what they wanted to know, and their difficulty comprehending and accepting "bad news" was apparent in both qualitative and quantitative data. Our findings suggest that ineffective communication about end-of-life issues likely results from both physician's lack of discussion and family caregiver's difficulty hearing the news. Future studies should examine strategies for optimal physician-family caregiver communication about incurable illness, so that families and patients can begin the physical, emotional, and spiritual work that can lead to acceptance of the irreversible condition.

                Author and article information

                886-6-2353535 ext 5737 ,
                BMC Palliat Care
                BMC Palliat Care
                BMC Palliative Care
                BioMed Central (London )
                10 October 2018
                10 October 2018
                : 17
                [1 ]ISNI 0000 0004 0532 3255, GRID grid.64523.36, Institute of Gerontology, College of Medicine, , National Cheng Kung University, ; Tainan, Taiwan
                [2 ]ISNI 0000 0004 0572 899X, GRID grid.414692.c, Department of Family Medicine, , Buddhist Tzu Chi General Hospital, ; Hualien, Taiwan
                [3 ]ISNI 0000 0000 9476 5696, GRID grid.412019.f, Department of Psychology, , College of Humanities and Social Sciences, Kaohsiung Medical University, ; Kaohsiung, Taiwan
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, 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 ( applies to the data made available in this article, unless otherwise stated.

                Funded by: FundRef, National Science Council;
                Award ID: NSC 102-2410-H-006-123-
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