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How do medical residents discuss resuscitation with patients?
J A Tulsky1, M A Chesney, B Lo
1Robert Wood Johnson Clinical Scholars Program, University of California, San Francisco, USA.
Objective:
To describe how medical residents discuss do-not-resuscitate (DNR) orders with patients.
Design:
Prospective observational study.
Setting:
Inpatient medical wards of one university tertiary care center, one urban city public hospital, and one Veterans Affairs medical center.
Participants:
Thirty-one medical residents self-selected 31 of their English-speaking, competent patients, with whom they had DNR discussions.
Measurements:
Three independent observers rated audiotaped discussions about DNR orders between the medical residents and their patients. Ratings assessed whether the physicians met standard criteria for requesting informed consent (e.g., disclosed the nature, benefits, risks, and outcomes), addressed the patients' values, and attended to the patients' emotional concerns.
Main Results:
The physicians often did not provide essential information about cardiopulmonary resuscitation (CPR). While all the physicians mentioned mechanical ventilation, only 55% mentioned chest compressions and 32% mentioned intensive care. Only 13% of the physicians mentioned the patient's likelihood of survival after CPR, and no physician used a numerical estimate. The discussions lasted a median of 10 minutes and were dominated in speaking time by the physicians. The physicians initiated discussions about the patients' personal values and goals of care in 10% of the cases, and missed opportunities to do so.
Conclusions:
Medical ethicists, professional societies, and the public recommend more frequent discussions about DNR orders. Even when housestaff discuss resuscitation with patients, they may not be accomplishing the goal of increasing patient autonomy. Research and education must focus on improving the quality, as well as the quantity, of these discussions.