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[Decision to refrain from resuscitation in hospitals]
Insights
This study examined Do Not Resuscitate (DNR) orders in Norway, finding patients were elderly with high mortality. Patient involvement and documentation of decision-making capacity need improvement.
Area of Science:
- Medical Ethics
- Clinical Practice Guidelines
- Patient Care
Background:
- National guidelines for limiting life-prolonging treatment were published in Norway in 2009.
- The adherence of these guidelines in clinical practice remains unknown.
- This study investigates decision-making processes for Do Not Resuscitate (DNR) orders and associated patient demographics.
Purpose of the Study:
- To evaluate the clinical implementation of national guidelines on Do Not Resuscitate (DNR) orders.
- To understand the patient population receiving DNR orders.
- To analyze the decision-making process surrounding DNR orders.
Main Methods:
- Retrospective review of patient records from a local hospital's medical ward in 2012.
- Identification of patients with DNR orders using the DIPS patient record system.
- Assessment of decision-making competence based on available patient record information when not explicitly documented.
Main Results:
- 363 out of 12,522 hospitalized patients had DNR orders; average age was 82.5 years.
- Hospital mortality was 37%, and 30-day mortality was 66%.
- Patient competence for informed consent was often not explicitly documented, and 27% of competent patients were not involved in the decision.
Conclusions:
- Patients with DNR orders are typically elderly with high mortality and morbidity.
- Improved documentation of competence assessment for informed consent is crucial.
- Enhanced patient involvement in DNR decision-making is necessary for ethical and effective care.
Background:
In 2009, the Norwegian Directorate of Health published the national guidelines 'Decision-making processes in the limitation of life-prolonging treatment' (1). It is not known whether the recommendations in the guidelines are followed in clinical practice. The purpose of this study was to investigate the decision-making process when a DNR order has been issued to refrain from resuscitation and the patient group for whom such an order is made.
Material And Method:
The patients studied were hospitalised in the medical ward of a local hospital in 2012. Patients with a DNR order were identified through searches in 'critical information' in the DIPS patient record system. The study was conducted by means of a retrospective review of patient records with a follow-up time of two years. When competence to give informed consent was not recorded in the patient records, this was assessed based on other information in the records.
Results:
A total of 363 out of 12 522 patients hospitalised in 2012 were registered with DNR orders. Their average age was 82.5 years. Hospital mortality was 37 % and 30-day mortality 66 %. The DNR order was based on the patient's own wishes in 116 out of 363 patients. Altogether 64 % of these were women. Competence to give informed consent was never explicitly noted in the patient records. A total of 27 % of the patients who were assessed as competent to give informed consent were not involved in the decision.
Interpretation:
Patients with DNR orders are characterised by advanced age, mortality and morbidity. Clearer documentation of the assessment of competence to give informed consent, as well as better involvement of the patient, are necessary.
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