Futile cardiopulmonary resuscitation and physician authority for unilateral do not resuscitate orders

There is an emerging consensus today that specific case profiles exist in which in-hospital cardiopulmonary resuscitation (CPR) would be futile care and in which a do not resuscitate (DNR) order is medically appropriate. The physician's affirmative decision to perform CPR usually is made without involvement of the patient or the patient's family. On the other hand, DNR orders seldom are issued without consent of the patient or the patient's family, even though the patient is not likely to survive CPR. The concept of patient autonomy, however, does not extend to the patient and/or family a legal, ethical, or social right to futile care, particularly CPR that is futile. As such, the treating physician is not required to obtain the patient's and/or family's informed consent prior to issuing a DNR order, but has the unilateral authority to enter such an order.     

CPR or DNR? End-of-life decision in Korean cancer patients: a single center’s experience

Purpose Whether or not physicians should conduct cardiopulmonary resuscitation (CPR) in terminal cancer patients has long been debated. We conducted this prospective observational study to characterize current CPR and do-not-resuscitate (DNR) practice among terminal cancer patients in South Korea.Materials and methods The study involved patients with terminal cancer who were admitted at the Seoul National University Boramae Hospital for supportive care only, and who died between January 1, 2003 and April 30, 2004. We investigated the practices relating to the DNR directive, i.e., how many days before death was the directive effective, and from whom was it obtained.Results Of the enrolled 165 patients, 97 were male with a mean age of 65. Median duration of admission to death was 24 days (range 7–207, mean 31.7). The DNR directive was implemented in 143 patients (86.7%). All discussions about DNR took place between physician and family members, except in only one case. DNR directives were enacted at a median of 8.0 days (range 0–79, mean 12.15) before death. For 18 patients, the DNR directive was formally taken on the day of admission. In contrast, 14 cases (9.8%) were agreed on the day of death, 18.8% within 48 h of death, and 46.8% (67 of 143) within 1 week before death, 62% before 10 days, and 71.3% within 2 weeks. The worse the performance status of the patient, the earlier the DNR discussion was issued. Also, the lower the economic and educational status of the family member, the earlier the DNR directive was attained. Of the 165 patients with terminal cancer, CPR was performed in 13 cases (7.9%): in seven cases (4.2%) CPR was requested by a family member, and in six cases arrest occurred before DNR discussion was issued. None of the resuscitated patients survived.Conclusion In relation to DNR decisions in South Korean cancer patients, proxy decision-making is overwhelming and issuance of DNR discussion is raised at a late stage.     

Developing relationships with the board of directors

As a nurse administrator, you want to attend, or perhaps have already been invited to attend, meetings of your hospital's board of directors or trustees. What personal and professional strategies can you use, outside the board room, to foster your image as a powerful and competent administrator? Once in the board room, what is appropriate board etiquette? How can you contribute most effectively to board deliberations? The authors present strategies for establishing yourself as an influential, powerful, and valuable contributor to the executive management team as well as the board of directors.     

The ethical decision making process: a demonstration

Two issues identified from the scenario have been explored using the Ethical Decision Making Tree. Now look at some of the other issues identified earlier in this article work through the decision-making process using the Ethical Decision Making Tree. In looking at the use of experimental or futile care, what information would you need to gather and analyze? What personal values and moral positions need to be considered? Based on the previous two steps, what are the options? What is your decision and course of action? How are you going to evaluate the action taken to see if it worked or if other actions need to be taken? Remember, the solution is not what is best for you but what is best for the patient at this point of time.     

End-of-life decisions can be complex, even when patients have a DNR

Proactive communication with your patient and family members can clarify the decision-making process. Even if patient has a do-not-resuscitate (DNR) order, reconfirm patient's wishes when possible. Let family know if you do not believe a treatment will be efficacious. Initiate discussions with patients whom you think should consider having a DNR.     

Establishing incidence and administrative protocols for do not resuscitate orders

An order not to resuscitate refers only to CPR and does not imply the omission of any other type of medical care. Institutional DNR policies should include specific statements reflecting resuscitation for those without DNR orders, the patients' wishes, medical conditions, roles of family, protocol describing the process for DNR orders, scope of DNR orders, and frequency of review of DNR orders. The most common reasons for not having written DNR protocols were that directors of nursing did not have guidelines for or did not feel qualified to develop policies, and that they were not sure of the legal implications of such policies. An interagency ethics committee can serve as an advisory committee, but all medical and nursing decisions should be made by the appropriate professional, based on agency policy.     

Do Not Resuscitate orders and older patients: findings from an ethnographic study of hospital wards for older people

BACKGROUND AND AIM: This paper reports on the findings from an ethnographic study involving three wards in two hospitals in the Northwest of England and focuses on the controversial issue of Do Not Resuscitate (DNR) orders. The study aimed to explore the way in which terminal care was provided to older patients and examined the way in which DNR orders were a socially constructed part of the practices of both nurses and doctors. METHOD: An ethnographic approach was adopted that used participant observation and semi-structured interviews with nurses and doctors. A purposive sample of 28 qualified nurses and five medical staff were interviewed. The decision-making process of DNR orders became the focus of the interview questions. FINDINGS: The findings reveal that DNR decision-making was largely socially constructed from the interactions of hospital staff. Patients were not asked their preference and were excluded from any decision-making about Cardiopulmonary Resuscitation (CPR) or DNR orders. Two major findings emerge. First, DNR orders and the non-use of CPR could be seen as a form of medical beneficence, resulting from the often described paternalistic attitudes of hospital doctors. Second, there was a clear indication that DNR orders and the non-use of CPR for certain patients was based on improving the quality of patients' lives. CONCLUSION: The study raises issues about the quality of care received by frail older patients whom the nurses felt would not survive a futile medical procedure. The conclusion considers the need for hospitals to formulate and implement CPR policies, particularly in the prevailing climate in which patients are encouraged to become active participants in their own health care.     

Family affairs

It's no secret that your job is stressful, forcing you to deal with tragedy and death on a regular basis. You've become good at what you do because you pay attention to details and care about people. Most of the EMS providers I've known dedicate untold hours to their work, usually in addition to the regular jobs they hold. Their communities need them to be ready at a moment's notice when the pager sounds. Someone is in crisis. A life may hang in the balance-a life they may save. But what about the family that's left behind as you run out the door-yet again? How do your spouse/significant other and kids cope with whatever emotional state you're in when you return home? While your stress may be evident, their distress may be overlooked. What price do they pay to live with you? These questions were addressed during several workshops my colleagues and I conducted for EMS providers and their families. Many of the problems and frustrations identified in this article were shared by EMTs' family members who attended.     

帕金森病患者对疼痛认知体验质性研究

目的 了解帕金森病患者的疼痛体验及认知,为采取针对性疼痛护理措施提供依据。方法 运用质性研究中的现象学分析方法,对17例伴有疼痛的帕金森病患者进行半结构式访谈。访谈提纲包括6个问题：（1）您对帕金森病相关的疼痛了解吗?请您具体说说 （2）如果根据数字评分表(NRS)对疼痛进行评分,您觉得最高评分是多少? 可以谈谈您疼痛的感受吗?（3）当您感到疼痛时,您是如何应对的?（4）您是否向亲人或者医护人员主动说起您的疼痛经历?（5）您认为亲人和朋友的关心和支持对您重要吗?（6）针对帕金森病疼痛,您希望得到什么帮助呢?结果 共析出3个主题：疼痛体验深刻;对疼痛的应对不足;外源性支持不足。结论 疼痛严重影响帕金森病患者的生活质量,应重视患者的疼痛体验,加强知识宣教;关注居家照护,增加社会支持;立足评估治疗,加强疼痛管理,从而建立规范的疼痛管理模式,提高帕金森病患者的生活质量。     

Break the chains that blind. Keeping sight of your EMS career goals

Who controls your working life? Who is in the driver's seat of your EMS career? Do dead-end positions, poorly run organizations, frustrating managers, and family and financial commitments have you stuck in a rut? If so, there is something you can do. By following some basic steps, you can overcome these obstacles and reclaim your career--one that is fulfilling and satisfying.     

Important aspects of care and assistance for children with cancer

This study examined aspects of care and assistance that are important for 8- to 12-year-old children with cancer. Data were gathered through interviews with 25 children, 31 parents, and 32 nurses. Each participant was asked: “What caring aspects are important for you/your child/the child to feel cared for?” and “What help, if any, do you/your child/the child need outside the hospital?” Data were analyzed by content analysis. The following important caring aspects were identified: amusement, clinical competence, continuity, family participation, honest communication, information, participation in decision making, satisfaction of basic needs, social competence, and time. Children most frequently mentioned the importance of social competence, amusement, and satisfaction of basic needs. Parents and nurses most frequently mentioned the importance of information, social competence, and participation in decision making. The following important assistance aspects were also identified: emotional support, family life, meeting friends, practical support, rehabilitation, and school support. Two-thirds of the children did not mention that they needed any help outside the hospital. According to parents and nurses, one third of the children needed emotional support, whereas none of the children mentioned a need for this.     

What's in a name--or shape?

What does your organization chart look like? What titles do your various managers hold? For all of you who have spent so many serious hours developing organizational structures and lines of authority, the author asks you to sit back, relax, and take a break.     

Bridging the gap in emergency cardiac care

Your patient complains of chest pain. Within minutes he collapses in cardiac arrest. If you are a nurse working in a non-critical care area, where advanced medical care is not readily available, your immediate response is probably to initiate cardiopulmonary resuscitation (CPR). But is CPR enough? Should nurses be able to initiate more advanced care?     

Conceptual models: an assessment framework

What criteria would you use to assess the conceptual model you choose to guide your nursing department's practice? Whether you are assessing a model for your own use or critiquing someone else's, there are several considerations relating to the model's utility that should be kept in mind. To avoid choices based primarily on intuition or what "seems right," the author presents a framework for assessing the adequacy, completeness, and appropriateness of nursing models before their adoption for use in practice.     

Legitimating do-not-resuscitate orders: a discursive study of cancer patients' speech

This article examines how patients with cancer construct and legitimate do-not-resuscitate (DNR) orders. Semi-structured interviews with 23 outpatients attending an oncology clinic were tape-recorded, transcribed, and analyzed in accordance with discourse-analytic methodology. Results indicate some variability for participants regarding the meaning of DNR orders, which were nonetheless viewed as appropriate and desirable. The patient's subsequent death was legitimated primarily through the invocation of highly valorized discourses within Western society: nature, autonomy, and compassion. Non-compliance with DNR orders, or the instigation of CPR was seen as violating nature, infringing autonomy, and as uncompassionate. The combined effect was to construct dying as a natural event which is the concern of the individual patient and their family, endorsing medical non-intervention in the process. This research provides support, from the patients' viewpoint, for a policy of non-intervention when death is imminent and inevitable, and for those questioning the wisdom of a default policy of initiating CPR on any hospitalized patient, especially those patients inevitably in the process of dying.     

You did what? Clinical errors in EMS

It was late and you were exhausted. You ran a call that didn't go the way you would have liked. Errors occurred. What actions do you take when your partner is making mistakes? When do you step in? Do you step in? What if there's more to the errors than you realize? This article provides guidelines for EMS personnel to consider when dealing with a scenario that contains clinical errors. Although not an all-inclusive list, the examples and solutions may be beneficial to providers, including rookies and veterans.     

Nursing algorithms

The search for creative approaches to staffing never ceases. What is correct staffing planning? How do you achieve control over your staffing budget? How do you justify your budget to the hospital's financial officer? This article presents one hospital's modeling technique for projecting labor component budgets, establishing a flexible staffing assignment system, and instituting reporting systems for control.     

Caring for patients of diverse religious traditions: Islam, a way of life for Muslims

You have been a nurse for many years, yet you have never cared for a patient who practices Islam until now. You are assigned to a Muslim family for a home visit. What aspects about Muslim beliefs and way of life might be helpful to know before your visit?     

Advance directives: the New Zealand context

Advance directives convey consumers' wishes about accepting or refusing future treatment if they become incompetent. They are designed to communicate a competent consumer's perspective regarding the preferred treatment, should the consumer later become incompetent. There are associated ethical issues for health practitioners and this article considers the features that are relevant to nurses. In New Zealand, consumers have a legal right to use an advance directive that is not limited to life-prolonging care and includes general health procedures. Concerns may arise regarding a consumer's competence and the document's validity. Nurses need to understand their legal and professional obligations to comply with an advance directive. What role does a nurse play and what questions arise for a nurse when advance directives are discussed with consumers? This article considers the cultural dimensions, legal boundaries, consumers' and providers' perspectives, and the medical and nursing positions in New Zealand.     

Expert evidence: do you have all the facts?

As a practising expert witness, or an accident and emergency nurse considering the move into the challenging world of litigation, do you have all the facts about expert evidence to hand? What is your role in the proceedings? When could you be sued for the advice you give? Should you ever accept a case on a no-win, no-fee basis?