February 13, 2006

Practical Problems May Impede End of Life Talks

By Karla Gale

NEW YORK -- Guidelines in the UK advocate discussions with hospitalized patients regarding "do-not-resuscitate" (DNR) orders early after they are admitted. Although such discussions frequently do not take place, it is practical matters, rather than doctor resistance, that are often to blame, investigators have found.

With a DNR order, the patient states that should they suffer a cardiac arrest while hospitalized, they do not wish to be resuscitated.

"Twenty years ago there probably was a lot of paternalism, because physicians thought that it's far too upsetting to discuss these issues with patients," lead author Dr. H. Fidler told Reuters Health, "but the climate has changed. Now we're encouraged to include patients in all decisions regarding their healthcare."

To address this issue, Fidler and colleagues approached 374 adult patients within 24 hours of being admitted through the emergency department to the University Hospital Lewisham in London.

According to their report in the BMJ Online First, the investigators found that approximately half the subjects could not be approached for inclusion in the study. A further 111 declined to discuss resuscitation.

"During the first 24 hours the patient is extremely busy," Fidler explained. "They're being moved from ward to ward, they may be in X-ray or having investigations done, so practically it is difficult to find the opportunity to raise the issue. And there are other barriers as well, such as the patient being too unwell or too confused."

However, of the 74 patients who agreed to discuss resuscitation and DNR orders, 95 percent reported that they understood the information sheet about the subject, and 76 percent preferred that resuscitation decisions be discussed with them. Responses to an abbreviated state trait anxiety inventory suggested that the patients had reduced anxiety following the discussions.

Another barrier, Fidler pointed out, was simply a lack of knowledge about resuscitation: "Most of what little patients know comes from soap operas, but the information they get there is inaccurate, and it does not give very realistic ideas about outcomes."

"Maybe the best time to raise this issue is not when patients are acutely ill, but instead when they normally come in contact with their doctors, to have the information available," in the form of a leaflet or video recording, she suggested. "If there was better background information in the local population it would be much easier when people come into the hospital to raise the issue."

Finally, she noted that UK guidelines are not very specific, instead encouraging hospitals to set up their own policy about DNR discussion with patients and to audit it: "I think it's probably best to be left open-ended about when the discussion takes place rather than specifying that they take place during the first 24 hours after admission."

SOURCE: BMJ Online First, February 10, 2006.