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Guidelines for the use of do-not-resuscitate orders in Dutch hospitals
I Haverkate1, J J van Delden, A B van Nijen
1Institute for Research in Extramural Medicine, Vrije Universiteit Amsterdam, The Netherlands.
Insights
Sixty percent of Dutch hospitals have do-not-resuscitate (DNR) order guidelines, but these can be improved. Patient involvement in decisions regarding nonfutile resuscitation is high, yet living wills are not always respected.
Area of Science:
- Medical Ethics
- Healthcare Policy
- Clinical Practice
Background:
- Do-not-resuscitate (DNR) orders are critical for end-of-life care decisions.
- Standardized guidelines are essential for consistent and ethical DNR practices in hospitals.
Purpose of the Study:
- To determine the prevalence of DNR order guidelines in Dutch hospitals.
- To analyze the content and key features of existing DNR guidelines.
Main Methods:
- Cross-sectional descriptive study utilizing a nationwide survey.
- Questionnaires sent to patient care directors of all 143 Dutch hospitals.
- Content analysis of returned guidelines focusing on specific decision-making aspects.
Main Results:
- A 95% response rate was achieved, with 60% of hospitals having DNR guidelines.
- Guidelines frequently assumed "always resuscitate, unless" (66%) and emphasized patient involvement (93%).
- Respect for living wills in cases of incompetence was noted in 38%, with proxies primarily in a discussion role (58%).
Conclusions:
- The development of DNR guidelines in 60% of Dutch hospitals is a positive step.
- Significant opportunities exist to enhance current DNR guidelines for improved patient care and ethical practice.
Objectives:
To determine the prevalence and analyze the content of guidelines for the use of do-not-resuscitate (DNR) orders in Dutch hospitals.
Design:
Cross-sectional descriptive study.
Measurements And Main Results:
A questionnaire was mailed to the directors of patient care at all 143 Dutch hospitals. Directors were asked whether their hospitals had guidelines for the use of DNR orders and to provide copies of the guidelines if they did. The content of the guidelines was analyzed with regard to basic assumptions about nonresuscitation, definitions, persons involved in decision-making, advance directives, starting discussions about nonresuscitation, notation, evaluation, and other aspects. Of the 143 hospital directors surveyed, 95% responded. Sixty percent of the hospitals had guidelines for the use of DNR orders and provided copies. The assumption "always resuscitate, unless" was mentioned in 66% of guidelines. In 93% it was stated that patients should be involved in decision-making about nonfutile resuscitation. In 38% it was stated that in principle, living wills were respected in cases of incompetence. The role of proxies was mainly to discuss decisions (58% of guidelines), not to make them. The most frequently mentioned moment for starting a discussion about nonresuscitation was the onset of clinical deterioration of the patient (41%).
Conclusions:
It is promising that 60% of Dutch hospitals have developed guidelines for the use of DNR orders. However, current guidelines can be improved in many respects.