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Numerous times, TV medical dramas show a patient in cardiac arrest getting cardiopulmonary resuscitation (CPR), coming back to life, and being back to their old self in no time. In fact, being resuscitated is not so simple and can be dangerous in its own right. Given that, in many cases, the risks of pain and harm from CPR outweigh the benefits, it comes as no surprise that a growing number of people issue a do-not-resuscitate (DNR) order as part of their advance care plan to prevent CPR attempts on them should their heart or breathing stop. This legal document illustrates their aversion to euthanasia. For many, the idea of being kept alive via artificial means, such as life support, is more appalling than death itself. This study focuses on the concept of dying and the legal repercussions of a medical doctor (MD)'s refusal to perform CPR without the patient's consent, thus, allowing, the patient’s natural death to occur. What ought the MDs do and ask in a situation like this so as to avoid criminal responsibility? The result of this study is that deciding about DNR orders is a difficult process that can be affected by various factors. However, few legislations have codified the criminal responsibility of the doctor, as the UAE legislator did in Federal Decree-Law No. (4) of 2016 regarding Medical Liability. [ABSTRACT FROM AUTHOR]

Objectives: Latino patients have been shown to engage in advance care planning (ACP) at much lower rates than non-Latino White patients. Coping strategies, such as the use of emotional support, may differentially relate to engagement in ACP among Latino and non-Latino patients. The present study sought to examine the moderating effect of ethnicity on the relationship between the use of emotional support as a coping strategy and completion of advance directives. Methods: The present study employed a weighted sample (N w = 185) of Latino and non-Latino White patient participants in Coping with Cancer III, an National Institutes of Health–sponsored, multisite, longitudinal, observational cohort study of patients with advanced cancer and their informal caregivers and oncology providers designed to evaluate Latino/non-Latino disparities in ACP and end-of-life cancer care. Main and interaction effects of Latino ethnicity and use of emotional support on patient use of advance directives were estimated as odds ratios. Results: Use of emotional support was associated with dramatically lower do-not-resuscitate (DNR) order completion to a greater extent among Latino as compared to non-Latino patients (interaction AOR = 0.33, p = 0.005). Interaction effects were not statistically significant for living will or health-care proxy form completion. Significance of results: Use of emotional support is associated with lower odds of completing DNRs among Latino than among non-Latino patients. Seeking and/or receiving emotional support may deter Latino patients from completing DNR orders. Research is needed to address both emotional needs and practicalities to ensure high quality end-of-life care among Latino patients with cancer. [ABSTRACT FROM AUTHOR]

Do-not-resuscitate (DNR) orders should preclude the use of cardiopulmonary resuscitation and may be associated with patient outcomes for patients hospitalized with heart failure (HF). This study examined the association between DNR and costs, mortality, and length of stay. The study cohort was a national sample of 700 922 hospital admissions of patients aged >65 with a primary diagnosis of HF. Elderly HF patients who died with a DNR had cost-savings of $5640 (P < 0.001). Patients with a DNR order were 8.9% points more likely to die before discharge than patients without (P < 0.001), and patients who died with a DNR had a significantly shorter hospital stay by 1.51 days (P < 0.001). DNR orders among elderly patients with HF are associated with cost-savings, as well as a higher mortality and shorter length of stay. In addition to primary benefits, advance care planning may aid in containing costs of care at end of life for HF. [ABSTRACT FROM AUTHOR]

Introduction: The concept of futile therapy has become increasingly common among medical staff, especially in anaesthesiology and intensive care units (ICU), in recent years. Guidelines for limiting futile therapy are available, but most ICU staff do not apply them. The aim of this study was to analyse the knowledge and views of Polish medical students on futile therapy. Material and methods: The survey was carried out among medical students. The first phase took place in 2019. After analysis and modification of the questionnaire, the survey was continued in 2022-2023. The questionnaire included questions about knowledge and understanding of the concept of futile therapy. Results: In the second phase, 231 students were surveyed. 74% of the students were familiar with the concept of futile therapy, but only 39% defined it correctly. 25% of students were aware of the existence of official Polish admission criteria to the ICU. 61% of students had encountered patients with futile therapy. 69% believed that futile therapy is limited to less than 30% of cases. Most of the students supported the introduction of the DNR declaration into Polish law. According to the students, the patient's condition/prognosis and the patient's will are the most important factors influencing the frequency of futile therapy. Withdrawing therapy is more difficult than withholding it. Conclusions: Medical students are aware of the problem of futile therapy but need more knowledge about it. To reduce the incidence of futile therapy in the future, it is necessary to educate students, especially about the existing admission criteria to the ICU. Withdrawing therapy is more difficult than withholding it; therefore, early use of protocols to limit futile therapy should be promoted. [ABSTRACT FROM AUTHOR]

Background: Older adults suffering from traumatic brain injury (TBI) are subject to higher injury burden and mortality. Do Not Resuscitate (DNR) orders are used to provide care aligned with patient wishes, but they may not be equitably distributed across racial/ethnic groups. We examined racial/ethnic differences in the prevalence of DNR orders at hospital admission in older patients with severe TBI. Methods: We conducted a retrospective cohort study using the National Trauma Databank (NTDB) between 2007 to 2016. We examined patients ≥ 65 years with severe TBI. For our primary aim, the exposure was race/ethnicity and outcome was the presence of a documented DNR at hospital admission. We conducted an exploratory analysis of hospital outcomes including hospital mortality, discharge to hospice, and healthcare utilization (intracranial pressure monitor placement, hospital LOS, and duration of mechanical ventilation). Results: Compared to White patients, Black patients (OR 0.48, 95% CI 0.35-0.64), Hispanic patients (OR 0.54, 95% CI 0.400.70), and Asian patients (OR 0.63, 95% CI 0.44-0.90) had decreased odds of having a DNR order at hospital admission. Patients with DNRs had increased odds of hospital mortality (OR 2.16, 95% CI 1.94-2.42), discharge to hospice (OR 2.08, 95% CI 1.75-2.46), shorter hospital LOS (-2.07 days, 95% CI -3.07 to -1.08) and duration of mechanical ventilation (-1.09 days, 95% CI -1.52 to -0.67). There was no significant difference in the utilization of ICP monitoring (OR 0.94, 95% CI 0.78-1.12). Conclusions: We found significant racial and ethnic differences in the utilization of DNR orders among older patients with severe TBI. Additionally. DNR orders at hospital admission were associated with increased in-hospital mortality, increased hospice utilization, and decreased healthcare utilization. Future studies should examine mechanisms underlying race-based differences in DNR utilization. [ABSTRACT FROM AUTHOR]

Abstract Background The acceptance or practical application of the do-not-resuscitate order is substantially dependent on internal or personal factors; in a way that decision-making about this issue can be specific to each person. Moreover, most nurses feel morally and emotionally stressed and confused during the process decision-making regarding DNR order. Therefore, the purpose of the present study was to evaluate nurses’ attitudes towards DNR order in a systematic review. Methods This critical survey was conducted using a systematic review protocol. To this end, the most relevant articles published in domestic and foreign databases with no time limits until October 2018 were searched. The inclusion and exclusion criteria were articles on DNR order, studies about nurses’ attitudes, descriptive and analytical research papers, as well as those with download links and full texts. The given articles were also assessed in terms of their quality and their main results were extracted. Results Of the total number of 1663 articles searched in the process of systematic review to investigate nurses’ attitudes towards DNR order, 88 articles were included in the full-text review step and finally 10 articles, meeting the inclusion criteria, were found. Assessing the quality of articles included in this review showed that 8 articles, in general, were of good quality and 2 studies were characterized with moderate quality. The main factors associated with nurses’ attitudes towards DNR order were grouped into three categories of (1) nurses’ attitudes towards DNR order, (2) guidelines for DNR order, and (3) decision-making by patients and their families about DNR order. In most of the studies examined, nurses’ attitudes towards DNR order were reported positive. Conclusion It seemed that nurses were willing to get involved in DNR order and each hospital was recommended to develop a written DNR policy directing individuals and avoiding their confusion in this respect.

BACKGROUND: Making appropriate decisions for cardiopulmonary resuscitation (CPR) is very challenging for healthcare providers. This study aimed to evaluate knowledge, attitude, and decision making about do-not-resuscitate (DNR) and termination of resuscitation (ToR) among nurses in the resuscitation team. METHODS: This descriptive cross-sectional study was conducted in April-September 2020. Participants were 128 nurses from the CPR teams of two hospitals in Kermanshah and Hamedan, Iran. A valid and reliable researcher-made instrument was used for data collection. Data were analyzed using the Chi-square, Fisher's exact, and Mann-Whitney U tests, the Spearman's correlation analysis, and the logistic and rank regression analyses. RESULTS: Only 22.7% and 37.5% of participants had adequate knowledge about ToR and DNR. The significant predictor of DNR and ToR knowledge was educational level and the significant predictors of decision making for CPR were educational level, gender, and history of receiving CPR-related education (P<0.05). When facing a cardiac arrest and indication of DNR or ToR, 12.5% of participants reported that they would not start CPR, 21.5% of them reported that they would terminate CPR, and 14.8% of them reported that they would perform slow code. The DNR decision had significant relationship with educational level, DNR knowledge, and ToR knowledge (P< 0.05), while the ToR decision had significant relationship with educational level and ToR knowledge (P<0.05). CONCLUSION: Nurses' limited DNR and ToR knowledge and physicians' conflicting orders and documentation can cause ethical challenges for nurses. Clear guidelines for DNR orders or TOR is necessary for nurses, in order to prevent any potential confusion, legal or psychosocial issues and concerns surrounding CPR and improve their involvement in CPR decision making process. [ABSTRACT FROM AUTHOR]

Background: The acceptance or practical application of the do-not-resuscitate order is substantially dependent on internal or personal factors; in a way that decision-making about this issue can be specific to each person. Moreover, most nurses feel morally and emotionally stressed and confused during the process decision-making regarding DNR order. Therefore, the purpose of the present study was to evaluate nurses' attitudes towards DNR order in a systematic review.Methods: This critical survey was conducted using a systematic review protocol. To this end, the most relevant articles published in domestic and foreign databases with no time limits until October 2018 were searched. The inclusion and exclusion criteria were articles on DNR order, studies about nurses' attitudes, descriptive and analytical research papers, as well as those with download links and full texts. The given articles were also assessed in terms of their quality and their main results were extracted.Results: Of the total number of 1663 articles searched in the process of systematic review to investigate nurses' attitudes towards DNR order, 88 articles were included in the full-text review step and finally 10 articles, meeting the inclusion criteria, were found. Assessing the quality of articles included in this review showed that 8 articles, in general, were of good quality and 2 studies were characterized with moderate quality. The main factors associated with nurses' attitudes towards DNR order were grouped into three categories of (1) nurses' attitudes towards DNR order, (2) guidelines for DNR order, and (3) decision-making by patients and their families about DNR order. In most of the studies examined, nurses' attitudes towards DNR order were reported positive.Conclusion: It seemed that nurses were willing to get involved in DNR order and each hospital was recommended to develop a written DNR policy directing individuals and avoiding their confusion in this respect. [ABSTRACT FROM AUTHOR]

Shunsuke Kojima,1 Eiji Hiraoka,1 Junya Arai,1 Yosuke Homma,2 Yasuhiro Norisue,3 Osamu Takahashi,4 Taihei Soma,1 Toshihiko Suzuki,5 Masahiko Noguchi,6 Kentaro Shibayama,6 Kotaro Obunai,6 Hiroyuki Watanabe6 1Department of Internal Medicine, 2Department of Emergency Medicine, 3Department of Critical Care and Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu-city, Chiba 279-0001, Japan; 4Department of Internal Medicine, St Luke’s International Hospital, Chuo-ku, Tokyo 104-8560, Japan; 5Department of Nephrology, Endocrinology, and Diabetes, 6Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu-city, Chiba 279-0001, Japan Background: A do-not-resuscitate (DNR) order is reportedly associated with a decrease in performance measures, but it should not be applied to noncardiopulmonary resuscitation procedures. Good performance measures are associated with improvement in heart failure outcomes.Aim: To analyze the influence of DNR order on performance measures of heart failure at our hospital, where lectures on DNR order are held every 3 months.Design: Retrospective cohort study.Methods: The medical report of patients with acute heart failure who were admitted between April 2013 and March 2015 were retrospectively analyzed. We collected demographic data, information on the presence or absence of DNR order within 24 hours of admission, and inhospital mortality. Performance measures of heart failure, including assessment of cardiac function and discharge prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and beta-blocker for left ventricular systolic dysfunction and anticoagulant for atrial fibrillation, were collected and compared between groups with and without DNR orders.Results: In 394 total patients and 183 patients with left ventricular systolic dysfunction, 114 (30%) and 44 (24%) patients, respectively, had a DNR order. Patients with a DNR order had higher inhospital mortality. There were no significant differences between the two groups in terms of the four quality measures (left ventricular function assessment, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, and anticoagulant).Conclusion: DNR orders did not affect performance measures, but they were associated with higher inhospital mortality among acute heart failure patients. Keywords: do-not-resuscitate discussion, DNR order, acute heart failure, quality-of-care performance

Objective: To determine the short-term outcomes of babies for whom clinicians or parents discussed the limitation of life-sustaining treatment (LST).Design: Prospective multicentre observational study.Setting: Two level 3, six level 2 and one level 1 neonatal units in the North-East London Neonatal Network.Participants: A total of 87 babies including 68 for whom limiting LST was discussed with parents and 19 babies died without discussion of limiting LST in the labour ward or neonatal unit.Outcome Measures: Final decision reached after discussions about limiting LST and neonatal unit outcomes (death or survived to discharge) for babies.Results: Withdrawing LST, withholding LST and do not resuscitate (DNR) order was discussed with 48, 16 and 4 parents, respectively. In 49/68 (72%) cases decisions occurred in level 3 and 19 cases in level 2 units. Following the initial discussions, 34/68 parents made the decision to continue LST. In 33/68 cases, a second opinion was obtained. The parents of 14/48 and 2/16 babies did not agree to withdraw and withhold LST, respectively. Forty-seven out of 87 babies (54%) died following limitation of LST, 28/87 (32%) died receiving full intensive care support, 5/87 (6%) survived following a decision to limit LST and 7/87 (8%) babies survived following decision to continue LST.Conclusions: A significant proportion of parents chose to continue treatment following discussions regarding limiting LST for their babies, and a proportion of these babies survived to neonatal unit discharge. The long-term outcomes of babies who survive following limiting LST discussion need to be investigated. [ABSTRACT FROM AUTHOR]

Background: A suicidal person with a do-not-resuscitate (DNR) order presents an ethical dilemma to the emergency physician. Many believe that suicide is an irrational action, and therefore, all suicide attempts must be treated. Others believe a DNR order should be respected even in the setting of a suicide attempt.Case Report: An elderly woman with a known terminal illness presented to the emergency department after a suspected suicide attempt. She had a DNR order during her previous hospitalization. The emergency physician felt obligated to intubate the woman despite his recognition that she was terminally ill.Discussion: Reasons to both honor and not honor a DNR order after a suicide attempt are reviewed.Conclusion: Not all patients who attempt suicide are necessarily incapable of making a rational decision about their health care. In some cases it may be appropriate to withhold resuscitation attempts in suicidal patients who have a preexisting DNR order. Institutional policies are needed to provide guidance in this situation. [ABSTRACT FROM AUTHOR]

Resuscitation has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort, and consume resources. The do-not-resuscitate (DNR) order and advance directives are still a debated issue in critical care. This review will focus on several aspects, regarding withholding and/or withdrawing therapies and advance directives in different continents. It is widely known that there is a great diversity of cultural and religious beliefs in society, and therefore, some critical ethical and legal issues have still to be solved. To achieve a consensus, we believe in the priority of continuing education and training programs for health care professionals. It is our opinion that a serious reflection on ethical values and principles would be useful to understand the definition of medical professionalism to make it possible to undertake the best way to avoid futile and aggressive care. There is evidence of the lack of DNR order policy worldwide. Therefore, it appears clear that there is a need for standardization. To improve the attitude about the DNR order, it is necessary to achieve several goals such as: increased communication, consensus on law, increased trust among patients and health care systems, and improved standards and quality of care to respect the patient's will and the family's role. [ABSTRACT FROM AUTHOR]

Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed., Competing Interests: Declaration of Competing Interest I have no conflicts to disclose., (Copyright © 2022. Published by Elsevier Inc.)

Abstract: Context: Prior studies suggest that terminally ill patients who use religious coping are less likely to have advance directives and more likely to opt for heroic end-of-life measures. Yet, no study to date has examined whether end-of-life practices are associated with measures of religiosity and spirituality. Objectives: To assess the relationship between general measures of patient religiosity and spirituality and patients'' preferences for care at the end of life. Methods: We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center. Primary outcomes were whether the patient had an advance directive, a do-not-resuscitate (DNR) order, a durable power of attorney for health care, and an informally designated decision maker. Primary predictors were religious attendance, intrinsic religiosity, and self-rated spirituality. Results: The sample population (n =8308) was predominantly African American (73%) and female (60%). In this population, 1.5% had advance directives and 10.4% had DNR orders. Half (51%) of the patients had specified a decision maker. White patients were more likely than African American patients to have an advance directive (odds ratio [OR] 2.1; 95% CI 1.1–4.0) and a DNR order (OR 1.7; 95% CI 1.0–2.9). Patients reporting high intrinsic religiosity were more likely to have specified a decision maker than those reporting low intrinsic religiosity (OR 1.3; 95% CI 1.1–1.6). The same was true for those with high compared with low spirituality (OR 1.3; 95% CI 1.1–1.5). Religious characteristics were not significantly associated with having an advance directive or DNR order. Conclusion: Among general medicine inpatients at an urban academic medical center, those who were highly religious and/or spiritual were more likely to have a designated decision maker to help with end-of-life decisions but did not differ from other patients in their likelihood of having an advance directive or DNR order. [Copyright &y& Elsevier]