1. DNR: Survey of the Discussions by Medical Professionals at a Tertiary Care Center
Danielle Cobb, MD; Peggy White, MD; Terrie Vasilopoulos, PhD; Laurie Davies, MD; Brenda Fahy, MD
Department of Anesthesiology, University of Florida College of Medicine, Gainesville
Background
Discussion
Results
The passage of the 1990 Patient Self-Determination Act in the United States requires healthcare institutions that receive any federal funding to inform patients of their rights concerning medical decision, including the right to refuse life-sustaining therapies including cardiopulmonary resuscitation (1). Although it has been more than 25 years since this legislation was passed, the Institute of Medicine in 2014 published "Dying in America", that advocated discussions between clinicians and patients concerning advance care planning and end of life care preferences (2). The focus of our study was to survey how these discussions, including refusal of life-sustaining therapies and the Do Not Resuscitate (DNR) order occur by professionals in a tertiary medical center. Factors analyzed that might influence these discussions include medical professional background (e.g. nurse, physician) and specialty expertise, level of training practice experience, and gender.
Overall, more than one-third of responded reported rarely or never discussing end-of-life issues with their patients. Specialty (P<0.001) and medical profession (P=0.006) remained as independent predictors in multivariable analyses. A majority of critical care and emergency medicine practitioners (55%) reported frequently (always or most of the time) discussing discussing end-of-life issues (Fig 1). However, for the specialties of surgery (77%), anesthesiology (56%), and pediatrics (61%), the majority of respondents reported infrequent (rarely or never) end-of-life discussions with patients (Fig 1). Physicians in Training (33%) and Registered Nurses (30%) reported frequently (always or most of the time) discussing end of life issues (Fig 2).
In a survey conducted in two tertiary care institutions, the most striking data is that over one-third of healthcare providers across all disciplines responded "never" or "almost never" when asked "Do you discuss end-of-life issues with your patients?" These results call into question how much forward progress, if any, has resulted from the enactment of the Self-Determination Act of Critical Care practitioners were noted to be a specialty that had frequent conversations and speaks to the role of critical care providers in end-of-life decisions. Medical professional could benefit from additional training and hands-on experience with end-of-life discussions. These discussions are high stakes and healthcare providers could take advantage of simulation as one avenue for future studies.
Methods
The survey was constructed using Qualtrics, an online survey-collection program. Following Institutional Review Board approval, the survey with the methodology and informed consent was distributed to faculty physicians, physicians in training, registered nurses, physician assistants, and nurse practitioners at the University of Florida (two campuses separated by 100 miles) to assess the demographics of respondents and the frequency of DNR discussions. Measures were summarized by the proportion (%) of respondents. The survey asked "Do you regularly talk to your patients of end-of-life wishes?" with answering options being "Always", "Most of the Time", "Sometimes", "Rarely", and "Never". Chi-square tests were used to separately assess the relationship between age, gender, specialty, medical profession, and experience. Multivariable logistic regression analysis was used to assess the independent prediction value of these measures. P<0.05 was considered statistically significant.
References
1. Omnibus Budget Reconciliation Act of 1990 (OBRA-90; Pub. L , 104 Stat. 1388, 4206 and 4751 [Medicare and Medicaid, respectively], 42 U.S.C cc(a) (I)(Q), 1395 mm (c) (8), 1395 cc(f), 1396a(a), 1396a(a), and 1396a(w). Enacted November 5, 1990)
2. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC, National Academies Press, 2014
Figure 1
Figure 2
Acknowledgments