Aspects of physicians regarding Do Not Resuscitate (DNR) willingness of patients with end-stage disease. How is the clinical practice without a legal framework?

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RESEARCH ARTICLE

Hippokratia 2024, 28(2): 65-71

Analyti A1, Schizas N1, Nazou G2, Xanthos T3
1National and Kapodistrian University of Athens
2Evangelismos General Hospital
Athens, Greece
3European University Cyprus, School of Medicine, Nicosia, Cyprus

Abstract

Background: Greece is a country without a legal legislature or legally advocated document for Do Not Resuscitate (DNR), where the physician dominates the DNR decision-making process. This study examines physicians’ beliefs regarding the shortage of a legal legislature and how its existence would impact clinical practice.

Methods: We conducted this study utilizing a questionnaire distributed to physicians of various specialties serving in two central general hospitals, regardless of the years of their clinical experience, commencing from October 2021 to May 2022. The questionnaire included questions regarding participants’ characteristics and aspects of physicians’ willingness to accept DNR in end-stage disease or critically ill patients.

Results: We included 132 participants with a mean age of 41.6 years, including physicians from various surgical or pathological specialties with a male predominance (55.3 % male). The study’s findings indicate that personal judgement and clinical experience outweigh the typical criteria for applying cardiopulmonary resuscitation (CPR) (p =0.002). Married participants, pathologists, and experienced physicians have a greater demand for a legal framework and, consequently, reduced legal and ethical dilemmas. Almost half of participants (47.7 %) strongly support that CPR is used just to delay the imminent death. In a percentage of 5.3 %, physicians proceeded to CPR against the verbal preference of patients or relatives for DNR. The great majority of patients (94.5 %) are positive regarding establishing legislative regulations and creating documents about DNR in end-stage disease or critically ill patients.

Conclusions:This study’s findings depict the need to regulate DNR in end-stage disease or critically ill patients after informed consent. Patient rights preservation and physicians’ clinical dilemmas during decision-making process avoidance are undoubtful benefits of such legislative reforms. HIPPOKRATIA 2024, 28 (2)65-71.

Keywords: Do not resuscitate, DNR, ethics, informed consent, cardiopulmonary resuscitation

Corresponding author: Nikolaos Schizas, MD, MSc,27 Pindoustr.,15235Vrilissia, Greece, tel.: +306936820715, e-mail: nikschizas@gmail.com

Introduction

End-stage disease patients constitute a category of patients with increased needs demanding special care. As the disease progresses, these patients become familiar with the idea of death and often request to be left untreated in case of cardiopulmonary arrest without implementing cardiopulmonary resuscitation (CPR). This statement is authorized and defined by legislation in many countries, while others avoid establishing regulations on this domain. This is commonly known as the Do Not Resuscitate (DNR) statement, a binding formal document declaring the willingness of the patient to be left untreated in case of cardiopulmonary arrest, and the law recognizes this willingness1. This decision should be made when the patient is fully conscious, emotionally stable, and well-informed about his medical condition2.

Managing such situations is complicated, as different health professionals are involved and must be capable of providing the best health services for the patient concerning his/her willingness3.The guideline protocols also include information regarding DNR patients and their management4. Although most health professionals know what they have to do in theory, in clinical practice, things are different. Moreover, legislation in many countries needs to be revised in this domain. Consequently, due to the fact that they have more responsibilities, health professionals, especially physicians, find themselves unprotected and stressed in decision-making5.Respectively, there is no definite legislation regarding such issues in the Greek legislative system6.

In this light, the current study focuses on the aspects of physicians working in the Greek National Hospital System (GNHS) regarding the cases of patients suffering from end-stage disease with the intention of DNR. This data is interesting, considering that Greek legislation has no regulations in this domain.

Methods

This research aims to investigate the aspects of Greek physicians of all specialties working in the GNHS regarding DNR in patients with end-stage disease. Additionally, this study investigates the impact of a specific regulation on DNR on daily medical practice.

We conducted this study in two general hospitals from January 2022 to June 2022. Through personal interviews, the participants completed a questionnaire of 20 points that included five questions on the participants’ characteristics and 15 questions on the research subject. One hundred thirty-two physicians of all specialties and degrees participated in the survey through direct interviews. We conducted the study after obtaining the National Kapodistrian University of Athens Medical Faculty’s Bioethics Committee’s written approval (decision No 87, date 21/9/2021). All physicians who participated were fully informed regarding the purpose of the study, and the entire investigating and experimenting process was according to the Declaration of Helsinki and the Greek legislation in Bioethics. All participants’ data and rights were protected according to existing laws regarding personal data.

In this study, physicians from different specialties (pathologists and surgeons) participated voluntarily, regardless of their hierarchic position. The exclusion criteria consisted of: a) physicians working in the emergency unit department, as they do not often handle end-stage disease patients fully conscious; b) physicians in the intensive care unit as the patients of these departments are usually under sedation or intubated and lack decision-making capability; c) physicians that have clearly consulting role in the management of such patients (etc. endocrinologists); and d) physicians with specialty excluding trainees.

Statistical analysis

We present descriptive statistics to summarize participants’ characteristics, including frequency and percentage for qualitative and mean ± standard deviation for quantitative variables. We conducted an exploratory factor analysis to assess construct validity, decrease the number of variables, and disclose underlying structures. We chose principal component analysis as the extraction procedure using Varimax rotation and applied the Kaiser-Meyer-Olkin method to estimate sample adequacy.The cut-off point for Eigenvalues was 1.00, and for factor loadings was 0.40. We used the intraclass correlation coefficient to evaluate the questionnaire’s reliability in the test-retest procedure. We determined internal consistency reliability by the Cronbach’s alpha coefficient calculation. Scales with reliability equal to or greater than 0.70 were considered acceptable. We utilized multiple linear regression analyses with dependent factors emerging from the exploratory factor analysis. We computed adjusted regression coefficients (β) with standard errors from the results of the linear regression analyses. We conducted regression analyses after having logarithmically transformed the dependent variables. We set statistical significance at a p-value <0.001; all reported p-values are two-tailed. We conducted analyses utilizing IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA). 

Results

The sample consisted of 132 participants with a mean age of 41.6 ± 10.7 years. Their attributes are presented in Table 1. Most participants were men (55.3 %), married (56.8 %), and had children (92.1 %). Half of the participants (54.6 %) were specialists in internal medicine, while the mean clinical practice duration was 14.3 ± 10.2 years. Nearly all participants (97.7 %) had basic CPR training, with 47 % considered experts, and 37.1 % performed CPR on more than 100 patients.

Participants’ opinions regarding CPR and legal regulations are presented in Table 2. Half of the participants stated that family members participated “much/very much” in DNR/do not attempt resuscitation (DNAR) decisions regarding critically ill/terminally ill patients. Furthermore, 95.4% of the participants believed “much/very much” that there should be a legal regulation or legally supported document regarding DNR/DNAR decisions in critically ill/terminally ill patients. Only 5.3% of the participants had performed CPR despite the wishes of the patient or their family.

We applied the test-retest procedure to 15 participants. There was significant agreement between the two evaluations in all questionnaire elements (Table 3).

We evaluated the sampling adequacy of exploratory factor analysis through a Kaiser-Meyer-Olkin of 0.56 and a significant Barletts’ sphericity (p <0.001). After Varimax rotation, the principal component analysis of the 13 items revealed three factors (Table 4). All factors combined explained 44.6 % of the variance. Factor “Criteria for applying CPR” had five elements and explained 17.6 % of the variance. The “Dilemmas and legal frame about applying CPR” factor had four elements and explained 15.3 % of the variance. The “Doctor’s personal acumen in applying CPR” factor also had four elements and explained 11.6 % of the variance. All 13 elements had loading at least 0.40, and no secondary loadings were found. We summed elements across the factors and divided their sums by the number of the items. All factors had acceptable reliability since their Cronbach alpha coefficient was above 0.7.

When we conducted multiple linear regression, it was discovered that the number of times involved in CPR was significantly associated with the factor “Criteria for applying CPR” (Table 5). More specifically, participants who applied CPR 50-100 times or more than 100 times had significantly lower scores on this particular factor than participants who had applied CPR less than 10 times. Likewise, participants practicing internal medicine specialty and those with greater clinical experience had more outstanding scores in the “Dilemmas and legal frame about applying CPR” factor. Moreover, women had significantly greater scores in the factor “Doctor’s personal acumen in applying CPR”, while practicing an internal medicine specialty and having greater clinical experience were associated with lower scores in the factor above.

Discussion

This study investigates the beliefs and views of physicians of various specialties who deal with end-stage disease patients regarding DNR intention. DNR and other end-of-life issues in a country are determined by four main factors, including local legislation, the aspects of physicians in such matters, the willingness of the relatives, and the beliefs of each society according to religion, cultural beliefs, and worldview7.A large study from Dutch hospitals found that other factors affecting DNR are age, as it is more often in patients older than 80 years (66.4 % of DNR cases), and the administration of many medications, as patients using more than ten drugs represent 45.3 % of cases8. It is worth mentioning that even when there is legislation regarding DNR issues, physicians cannot use these tools properly9.

The study sample consisted of 132 individuals (55.3 % men) with a mean age of 41.6 years; 56.8 % were married, and 54.6 % practiced an internal medicine specialty. The results show that clinical experience plays a principal role in the criteria for applying CPR (p=0.011). Furthermore, it is evident from this study that married people (p =0.004), doctors with increased years of clinical experience (p <0.05), and practicing an internal medicine specialty (p =0.03) have a greater need for a legal framework and consequently reduced legal and ethical dilemmas. Notably, the years of clinical experience appeared to play a decisive role in the physician’s personal judgment regarding CPR application (p =0.002). Our findings suggest that personal aspects of physicians outweigh clinical protocols in decision making for resuscitation, as half of them have answered that decisions are based mainly on personal judgement. More specifically, their choices are made predominantly from their scientific point of view without undoubtful criteria or in opposition to the patient’s willingness. This action can sometimes conflict with the fundamental medical principle of“do good, not harm”10.

In order to minimize the impact of personal beliefs and the insecurity of physicians, educational programs in this field are necessary. The knowledge of the legislation, the method of management of such cases and the improvement in communication skills of the physicians are parameters that can be beneficial in ensuring patient’s capability to take his own decisions11. Another point of interest in managing such cases, is the timing of the discussion of DNR orders. It was found that end-stage disease patients with DNR orders decided more than three days from the day of demise received more psychological support and palliative care than those in whom the decision is taken within the three days preceding death. Also, in the earlier DNR orders group, fewer patients were transferred to the intensive care unit and wereintubated12.

About seven in ten participants of the study declared that the information provided to patients was satisfactory. In the question whether the end stage disease patient should be informed about the option of DNR, 29.5 % of patients support that this option shouldn’t be mentioned at all, while on the contrary similar percentage of patients supports that these patients must be fully informed about this choice. This finding highlights that physicians have different aspects ranging from “paternal” views to more liberal approaches. It should be mentioned that the tendency among physicians worldwide, especially in Western countries, is to provide all the information to the patient in order to make the decisions on his own13. Data from the East and, more specifically, from China showed that only half of the patients with in-hospital cardiac arrest had received DNRconsultation14.In any case, this data suggests that a high percentage, but not the majority of physicians, tend to be more conservative in decision-making, as they avoid discussing such matters with patients.

The results of this study show that 47.7 % of participants strongly support that CPR is used to delay imminent death. However, 5.3 % of physicians had proceeded to CPR against the oral intention of patients or relatives for DNR. These findings suggest that physicians feel unprotected and afraid of lawsuits if the CPR protocol is notperformed15. Definite legislative regulation improves the use of DNR in clinical practice, aiming substantially at physicians, although legislative changes without further actions lack achieving the desired outcomes16. Consequently, they follow the typical or defensive clinical practice to avoid legislative troubles, as the local law does not include such regulations.

The data collection time should also be commented on, as this study was conducted during the COVID. Indeed, during the pandemic of the coronavirus disease 2019 (COVID-19), such issues arose with serious dilemmas for physicians in daily practice17. The increased need for hospital beds during the pandemic affected more or less the aspects of physicians in DNR issues. More specifically, the DNR order was conceived as a rational choice in cases of futility in the United Kingdom due to COVID-19 compared to previous periods, leading to more ease in proposing DNR topatients18. This phenomenon was observed even in traditionally more conservative societies of the Islamic world, such as Iran, even though there were no legislative regulations in this direction19. Beliefs regarding DNR were affected by the COVID-19 pandemic for sure, but this is not necessarily positive. According to Fins, a new risk of expansion of physician’s paternalism over patients is emerging, as under the pressure of pandemic physicians may restrict patient’s autonomy in decision making20.

About three of four participants knew there was no legislative regulation regarding the willingness of patients or their relatives regarding DNR. Additionally, 67.4 % of physicians declared that a clearly defined law for written consent in this field would substantially impact doctors’ decisions and practice. Indeed, the tendency is to extend the patient’s autonomy, especially for end-stage and critically ill patients. Therefore, the discussions about patient-centered decisions after informed consent are increasing. So, except DNR, other intentions have appeared, such as Do Not Intubate (DNI) or Do Not Operate (DNO)21. Moreover, 94.5 % of the participants are positive about establishing the legislative regulation and document creation regarding DNR in patients with end-stage disease or those critically ill to ensure patients’ rights and make the decision-making process for physicians less stressful.

The main limitation of the current study is the necessity of broader data collection. While the sample was collected from two hospitals in one city, data from more hospitals from different regions is essential to improve the generability of reported outcomes.

Conclusions

The findings of this study depict the need for regulation of DNR in end-stage disease or critically ill patients after informed consent.Patient rights preservation and physicians’ clinical dilemmas during decision-making process avoidance are undoubtful benefits of such legislative reforms.

Conflict of interest

No conflicts of interest declared.

Acknowledgement

The statistical analysis was performed by Chara Tzavara, PhD biostatisian.

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