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Purpose Studies concerning do-not-resuscitate (DNR) orders in mainland China are rather scarce. We explored the prevalence and related factors of DNR orders among in-hospital cardiac arrest (IHCA) patients at a general tertiary hospital in mainland China. Materials and Methods We identified all IHCA patients hospital-wide between July 2019 and September 2020. Data regarding DNR status were collected from medical records. We investigated the frequency of DNR orders and explored the determinant factors of DNR establishment using logistic regression. Results A total of 1154 IHCA patients were included, 535 (46.4%) of whom established DNR orders. The following variables were independently associated with a higher DNR rate: female (OR 1.491; 95% CI 1.130–1.965), older age (OR 1.016; 95% CI 1.008–1.024), being a local resident (OR 1.790; 95% CI 1.344–2.383), pulmonary infection (OR 1.398; 95% CI 1052–1.859), respiratory insufficiency (OR 1.356; 95% CI 1.009–1.823), shock (OR 1.735; 95% CI 1.301–2.313), acute stroke (OR 1.821; 95% CI 1.235–2.686),neurological dysfunction (OR 1.527; 95% CI 1.149–2.028) and cancer (OR 3.316; 95% CI 2.461–4.468). Counterintuitively, patients with new-onset coronary artery disease (OR 0.592; 95% CI 0.419–0.837) were less likely to create DNR orders. Conclusion In mainland China, the DNR order signing rate is low, and the establishment of a DNR order is associated with demographics and comorbidity characteristics.

Objectives: Care for older adults with cancer became more challenging during the COVID-19 pandemic. We sought to examine cancer care providers' attitudes toward the barriers and facilitators related to the care for these patients during the pandemic. Materials and Methods: Members of the Advocacy Committee of the Cancer and Aging Research Group, along with the Association of Community Cancer Centers, developed the survey distributed to multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Participants were recruited by email sent through four professional organizations' listservs, email blasts, and messages through social media. Results: Complete data was available from 274 respondents. Only 15.4% had access to written guidelines that specifically address the management of older adults with cancer during the COVID-19 pandemic. Age was ranked fifth as the reason for postponing treatment following comorbid conditions, cancer stage, frailty, and performance status. Barriers to the transition to telehealth were found at the patient-, healthcare worker-, and institutional-levels. Providers reported increased barriers in accessing basic needs among older adults with cancer. Most respondents agreed (86.3%) that decision making about Do Not Resuscitate orders should be the result of discussion with the patient and the healthcare proxy in all situations. The top five concerns reported were related to patient safety, treatment delays, healthcare worker mental health and burnout, and personal safety for family and self. Conclusion: These findings demand resources and support allocation for older adults with cancer and healthcare providers during the COVID-19 pandemic.

Background Nurses and Doctor of Pharmacy (pharmD) must communicate and properly documented the do not resuscitate orders for terminally ill children and their relatives. They also have to offer excellent care including more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary cardiopulmonary resuscitation. This research was aimed to survey attitudes of nursing and pharmD undergraduate students about the "do not resuscitate" order for children with terminally ill diseases. Methods A cross-sectional correlational design was used to study the correlation between attitude toward DNR and demographic variables. More than 400 nursing and pharmD students from Jordan University of Science and Technology were recruited in this study. All the participating students were e-mailed information regarding the study, including the web survey link. Results The results showed that there was a significant difference in perception toward do not resuscitate order between nursing and pharmD students (p ≤ 0.05). The pharmD students had more positive attitude toward do not resuscitate than the nursing students. Approximately, 60% of the nursing and pharmD students would disclose the need for the do not resuscitate order for children with terminally ill diseases Demographic variables were not associated with the perception toward do not resuscitate orders (p ≥ 0.05). Conclusion This study showed that Jordanian nursing and pharmD students are willing to learn more about different aspects of do not resuscitate orders for terminally ill children. Analyzing their responses to many items showed their misconception about do not resuscitate orders for terminally ill children.

Background: Very few studies have investigated the racial differences in do-not-resuscitate (DNR) orders in children, and these studies are limited to oncological cases. We aim to characterize the ...

The aim of this study was to determine nurses’ opinions on Do Not Resuscitate (DNR) orders. This is a descriptive study. A total of 1250 nurses participated in this study. The mean age of participants was 34.5 ± 7.7 years; 92.6% were women; 56.4% had bachelor’s degrees, and 28.8% were intensive care, oncology, or palliative care nurses. Most participants (94.3%) agreed that healthcare professionals involved in DNR decision-making processes should have ethical competence, while they were mostly undecided (43%) about the statement whether or not DNR should be legal. More than half the participants (60.2%) disagreed with the idea that DNR implementation causes an ethical dilemma. Participants’ opinions on DNR decisions significantly differed according to the number of years of employment and unit of duty. The results showed that most of the nurses had positive attitudes towards DNR orders despite it being illegal. Future studies are needed to better understand family members’ and decision makers’ perceptions of DNR orders for patients.

A Do Not Resuscitate (DNR) order should only impede the performance of cardiopulmonary resuscitation in case of cardiac or respiratory arrest; it should not interfere with any other treatment decisions.To study the impact of DNR order placement on daily clinical care of patients.This was a retrospective cohort study of 72 patients in a tertiary care centre in Saudi Arabia. Daily clinical care measures were collected for 2 weeks prior and 2 weeks after DNR order placement and included vital signs, nursing care, comfort measures, documentation, visits by senior and junior physicians, and tests completed.Malignancy was the most common diagnostic category (43.1%). There was a significant reduction in vital signs documentation, tests completed, documentation, and visits by physicians after DNR orders, with no change in nursing care and comfort measures. No differences were seen for place of DNR order (intensive care unit vs medical ward), category of disease, or sex, but there were differences for documentation (more in females) and vital signs (more in males). More vital signs were documented and more tests were done in patients who survived compared to those who died. Regression analysis showed that the frequency of post-DNR order vital signs measurements and investigations done was not related to sex, age, diagnosis, time from admission to DNR order, or location of patients. Time to death was only related to sex and post-DNR order summary documentation.Placement of DNR orders significantly reduced vital signs measurements, investigations done, documentation and visits by physicians but not nursing care and comfort measures.تردد المرضى في قبول أمر "عدم الإنعاش": الآثار المترتبة على الرعاية السريرية.أمل الفرحان، منال الحارثي، منيرة بن موسى، عفاف مُقدم، حمدان جحدلي ، جنان شامو، عبد الله السياري، سليم باهارون.يجب أن يمنع أمر "عدم الإنعاش" أداءَ الإنعاش القلبي الرئوي فقط في حالة تَوَقُّف القَلْب أو التنفس؛ ولا يجب أن يتداخل مع أي قرارات أخرى للعلاج.دراسة أثر تنفيذ أمر "عدم الإنعاش" على الرعاية السريرية اليومية للمرضى.أُجريت دراسة أترابية استرجاعية شملت 72 مريضاً في أحد مراكز الرعاية الثالثية في المملكة العربية السعودية. وقد حُصرت تدابير الرعاية السريرية اليومية لمدة أسبوعين قبل أمر "عدم الإنعاش" وأسبوعين آخرين بعده، وشملت العلامات الحيوية، والرعاية التمريضية، وتدابير تحقيق الراحة، والتوثيق، وزيارات كبار وشباب الأطباء، وإتمام الفحوص.كان التشخيص بالإصابة بورم خبيث أكثر الفئات التشخيصية الشائعة (43.1٪). وقد حدث انخفاض ملحوظ في توثيق العلامات الحيوية، وإتمام الفحوص، والتوثيق، وزيارات الأطباء عقب إصدار أوامر "عدم الإنعاش"، مع عدم وجود أي تغيير في الرعاية التمريضية وتدابير تحقيق الراحة. ولم يُلاحَظ أي تغيير في تنفيذ أمر "عدم الإنعاش" (وحدة الرعاية المركزة مقابل الجناح الطبي)، أو فئة المرض، أو نوع الجنس، ولكن لوحظ بعض التباين من حيث التوثيق (أكثر في الإناث) والعلامات الحيوية (أكثر في الذكور). وكان معدل توثيق العلامات الحيوية وإجراء مزيد من الفحوص أعلى في المرضى الذين نجوا وظلوا على قيد الحياة عنه في الذين تُوفُّوا. وقد بيّ تحليل الانحدار أن وتيرة أخذ قياسات العلامات الحيوية والاستقصاءات عقب أمر "عدم الإنعاش" غير مرتبطة بنوع الجنس، أو العمر، أو التشخيص، أو المدة الزمنية من وقت دخول المستشفى وحتى صدور الأمر، أو مكان المرضى. وارتبطت الفترة الزمنية حتى الوفاة فقط بنوع الجنس وتوثيق ملخص ما بعد أمر "عدم الإنعاش".أدى تنفيذ أمر "عدم الإنعاش" بصورة كبيرة إلى خفض قياسات العلامات الحيوية، وإتمام الاستقصاءات، والتوثيق، وزيارات الأطباء، ولكن الأمر كان مختلفاً بالنسبة للرعاية التمريضية وتدابير تحقيق الراحة.Réticence du patient à accepter l’ordre de ne pas réanimer : conséquences sur les soins cliniques.Un ordre de ne pas réanimer doit seulement empêcher l’exécution de la réanimation cardio-respiratoire en cas d’arrêt cardiaque ou respiratoire ; il ne doit pas interférer avec d’autres décisions thérapeutiques.Étudier les conséquences de l’ordre de ne pas réanimer sur les soins cliniques quotidiens des patients.Il s’agissait d’une étude de cohorte rétrospective portant sur 72 patients d’un centre de soins tertiaires en Arabie saoudite. Des mesures des soins cliniques quotidiens ont été recueillies pendant deux semaines avant et deux semaines suite à l’émission de l’ordre de ne pas réanimer. Elles ont notamment pris en considération les signes vitaux, les soins infirmiers, les mesures de confort, la documentation, les visites des médecins principaux ou assistants et les examens effectués.La malignité était la catégorie de diagnostic la plus courante (43,1 %). On a constaté une réduction significative des mesures des signes vitaux, des examens effectués, de la documentation et des visites des médecins suite à l’émission des ordres de ne pas réanimer, sans aucun changement au niveau des soins infirmiers et des mesures de confort. Aucune différence n’a été constatée en ce qui concerne le lieu associé à l’ordre de ne pas réanimer (unité de soins intensifs ou service d’hospitalisation), la catégorie de la maladie ou le sexe, mais des différences ont été observées pour la documentation (plus détaillée chez les femmes) et la mesure des signes vitaux (plus fréquente chez les hommes). Les signes vitaux avaient davantage été documentés et plus d’examens avaient été effectués chez les patients qui ont survécu que chez ceux qui sont décédés. L’analyse de régression a montré que la fréquence de la mesure des signes vitaux et des examens effectués suite à l’émission de l’ordre de ne pas réanimer n’était pas liée au sexe, à l’âge, au diagnostic, au temps écoulé entre l’admission et l’émission de l’ordre de ne pas réanimer, ni au lieu de prise en charge du patient. Le délai avant le décès n’était lié qu’au sexe et à la documentation sommaire établie à la suite de l’émission de l’ordre.L’émission d’un ordre de ne pas réanimer réduisait de manière significative la mesure des signes vitaux, les examens effectués, la documentation et les visites des médecins, mais pas les soins infirmiers ni lesmesures de confort.

Advance directives are documents to convey patients’ preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient‐centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life‐Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.

Emeritus Professor Alan Glasper, from the University of Southampton, discusses concerns raised by the Care Quality Commission about the imposition of do not resuscitate orders on some patients during the pandemic

Introduction Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. While use of PCC is increasing, a prior study showed that less than 2% of patients with major burns had PCC during admission. The purpose of this study is to examine the impact of a protocol using recommended “triggers” for PCC at a single academic burn center. Methods This is a retrospective review of patient deaths over a four-year period (9/2016–8/2020). Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not resuscitate (DNR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended “triggers” for early (< 48 hrs of admission) PCC was instituted in 2019. Triggers included Baux score > 100 and/or complex decisions about treatment including need for cardiopulmonary resuscitation (CPR)/renal replacement therapy (RRT)/vasopressors, or at least two of the following: age > 70, major comorbidities, disagreement amongst family/patient/providers about best course of treatment, or no longer meeting expected milestones. Results A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42–72]. Median Baux score was 112 [IQR 81–133]. Eleven patients (33%) had major comorbidities. Many patients had life-sustaining interventions such as intubation, RRT, or CPR, often prior to admission. Amongst patients who survived >24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of patients having PCC before death (p=0.004). However, even during the later period, only half of patients had early PCC despite meeting criteria at admission. Conclusions Frequently, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended “triggers” for consultation, many patients who met criteria at admission did not receive early PCC.

The interpretation of do-not-resuscitate orders (DNRs) may vary in nonarrest situations. To reduce ambiguity, many hospitals allow patients to elect partial DNRs.To investigate the effect of partial DNRs on physicians' willingness to perform cardiopulmonary resuscitation (CPR) and nonarrest procedures.Cross-sectional study using scenario-based questionnaires between October 2015 and March 2016. A partial DNR was identified as a DNR with Adult Emergency Protocols (AEP) order. Each survey presented 3 patient scenarios followed by 10 interventions.Preclerkship and clerkship medical students, and internal medicine residents at a single medical school, and hospitalists at a tertiary-care academic medical center.Responses from 275 of 366 (75.1%) eligible subjects were collected. Compared to the case with a full DNR, the presence of a partial DNR was positively associated with subjects' willingness to provide both nonarrest procedures and CPR (p 0.05). The number of training or practice years was positively associated with a decision not to perform CPR: case 1 (odds ratio [OR], 1.09; confidence interval [CI], 1.04-1.16; p = 0.003); case 2 (OR, 1.07; CI, 1.01-1.14; p = 0.03); and case 3 (OR, 1.09; CI, 1.04-1.16; p 0.001).A partial DNR made our respondents more willing to provide nonarrest procedures, but also CPR. These findings suggest an ongoing need to develop better means of incorporating patients' goals of care into orders that more faithfully guide care for both nonarrest and arrest situations.

Background: This study aimed to profile the clinical pictures and identify the risk factors of mortality among terminally ill patients who visited the emergency department (ED) and had signed do-not-resuscitate (DNR) consents. Methods: This prospective study employed purposeful sampling of 200 adult, nontrauma, terminally ill patients who visited the ED and signed a DNR consent between July 1, 2011, and March 31, 2012. Physiological variables were compared between fatal and survival patients using Student's t-tests after assessing the normality of the data distribution. Results: The Cox proportional regression analysis revealed that patients taking antiarrhythmic drugs and vasopressor had a 47.6-fold and 2.8-fold higher mortality, respectively, compared to nonusers and those who had a respiratory rate ≥28 breaths/min showed a 2.8-fold increase in their risk of death compared to those with a respiratory rate

Aim and objectives This study aims to illustrate the Palestinian community's views, opinions and stances about the concept of do not resuscitate (DNR) for terminally ill patients. Background DNR orders are practiced in many countries worldwide, but there is no consensus on their practice in the Middle East. DNR orders may be applied for terminally ill pediatric patients. Some studies have been conducted describing people's experiences with these DNR orders. However, few studies have considered community perspectives on DNR orders for terminally ill patients in Palestine. Design A descriptive-qualitative design was adopted. Methods A purposive sample of 24 participants was interviewed, with consideration of demographical characteristics such as age, gender, education, and place of residency. The participants were recruited over a period of six months. Individual semi-structured interviews were utilized. These interviews were transcribed and analyzed using thematic analysis. Findings Significantly, the majority of the participants did not know the meaning of DNR, and thought that removal of life-sustaining devices and DNR were the same concept. Most of the interviewees adopted stances against DNR orders. Several factors were suggested to influence the decision of accepting or rejecting the DNR order. The majority of the participants mentioned religion as a major factor in forming their viewpoints. The participants expressed different views regarding issuing a law regarding DNR orders. Conclusion Our findings provide a unique understanding that there is a general misunderstanding amongst our participants regarding the DNR order. Further research with policymakers and stakeholders is still required. Relevance to Practice This study contributes to clarifying the perspectives of the Palestinian community regarding DNR. This may aid in facilitating communication between the health staff and patients’ families about end-of-life care decisions, and add to the growing literature regarding DNR orders in developing countries. This article is protected by copyright. All rights reserved.

Purpose: Palliative care (PC) has been shown to improve the quality of care and resource utilization for inpatients. We examined the relationship between PC consultation before and during final admission and patterns of care for dying patients at our tertiary cancer center. Methods: We retrospectively reviewed adult patients with solid tumor cancer with a length of stay ≥ 3 days who died in hospital between December 2012 and November 2014. We recorded services, including laboratory testing, imaging, blood products, medications, diet orders, do not resuscitate orders, and consultations, delivered within 3 days of death. We assessed the differences among services delivered to patients with outpatient PC, inpatient PC only, and no PC involvement. Results: Of 695 patients, 21% received outpatient PC, 46% received inpatient PC only, and 33% received no PC. During their final admission, 11.2% of patients received radiation therapy, and 12.5% received tumor-directed therapy, with no differences on the basis PC involvement ( P = .09 to .17). In the last 3 days of life, imaging tests occurred in 50.1%; patients with outpatient or inpatient-only PC underwent fewer studies (43.5% and 47.3%) than did those with no PC involvement (58.1%; P = .048). Do not resuscitate orders were in place within the 6 months before final admission at a greater rate for patients with outpatient PC (22%) than for patients with inpatient-only PC (8%) or those with no PC involvement (12%; P = .002). Conclusion: In this retrospective cohort of patients with solid tumor dying in hospital, few patients received cancer-directed therapies at the end of life. Involvement of PC was associated with a decrease in diagnostic testing and other services not clearly promoting comfort as patients approached death.

The study aimed to evaluate the effects of an advance care planning (ACP) program on knowledge and attitudes concerning palliative care, and decisions regarding DNR orders in the older residents in a long-term care institution.A quasi-experimental design was used. Participants were cognitively unimpaired older residents in a long-term care institution in Taiwan. The experimental group (n = 29) received the intervention including an individual interview using an ACP handbook and a group patient education; whereas the control group (n = 28) received the group patient education only.There were significant positive effects of the ACP program on understanding of DNR and palliative care, willingness to sign a DNR order, and knowledge of and attitude towards palliative care; however, there was no significant effect on willingness to receive palliative care. Six participants signed the DNR order after the intervention compared to none in the control group.The ACP program can improve knowledge and attitudes towards palliative care in older residents in long-term care institutions.The ACP program could incorporate multiple components, including individual interview using ACP handbook and group patient education, and address knowledge and attitudes towards palliative care.

Background Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR. Aim To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients. Methods A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer. Results When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03). Conclusion An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care.

Objectives: To determine the level of awareness of outpatients, their preferences regarding the appropriate time for discussions regarding do-not-resuscitate (DNR) order in Saudi Arabia. Methods: This cross-sectional, self-administered survey was conducted at King Fahd Medical City, a tertiary care hospital in Riyadh, Saudi Arabia between December 2012 and January 2013. Demographic parameters of the participants were analyzed by frequency distribution, and the data on their responses by percentage analysis. Results: The survey participants constituted 307 randomly selected outpatients/caregivers presenting for outpatient care at primary and tertiary care centers, 70% were female. Three-fourths of the participants had heard of DNR order, of which 50% defined it accurately. Ninety percent preferred a discussion while ill, and 10% while healthy. More than 70% expressed willingness to share the decision with their spouses/family members. Almost one-third believed DNR orders were consistent with Islamic beliefs, almost as many believed they were inconsistent, and almost a third did not take either position. Almost all the participants showed a willingness to learn more about the order. Conclusion: A divided opinion exists regarding religious and ethical aspects of the issue among the participants. However, almost all the participants showed a willingness to learn more about the DNR order. Saudi Med J 2017; Vol. 38 (3): 297-301 doi: 10.15537/smj.2017.3.18063 How to cite this article: Al Sheef MA, Al Sharqi MS, Al Sharief LH, Takrouni TY, Mian AM. Awareness of do-not-resuscitate orders in the outpatient setting in Saudi Arabia. Perception and implications. Saudi Med J . 2017 Mar;38(3):297-301. doi: 10.15537/smj.2017.3.18063.

Background: Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situa-tions. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient dis-tress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU. Methods: We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission. Results: Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001). Conclusions: Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associ-ated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further stud-ies are needed to clarify the guideline for end-of-life care in critically ill patients.

Masood Fallahi,1 Homayion Banaderakhshan,1 Alireza Abdi,1 Fariba Borhani,2 Rasool Kaviannezhad,3 Hassan Ali Karimpour4 1School of Nursing and Midwifery, 2Medical Ethics and Law Research Center, Medical Surgical Nursing Department, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, 3Department of Anesthesia, Paramedical School, Kermanshah University of Medical Sciences, 4Critical Care, School of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran Background: Physicians are responsible for making decisions about the do not resuscitate (DNR) order of patients; however, most of them are faced with some uncertainty in decision making and ethical aspects. Moreover, there are differences on decision making related to the DNR order among physicians, which may be related to the different attitudes toward this issue. Considering the lack of information, this study was performed to investigate doctors’ attitude about DNR order for patients in their final phases of life. Methods: In a descriptive–analytical study, 152 physicians were enrolled as quota sampling subjects from educational hospitals affiliated to the Kermanshah University of Medical Sciences. The tool used was a researcher-developed questionnaire. Data were analyzed using SPSS 16 software by descriptive and inferential statistics. Results: The mean of attitude toward DNR was 3.22, for which the univariate t-test showed a significant positive attitude toward DNR (P=0.002); the mean of attitude number toward DNR was higher in physicians with higher education level (P=0.002). But this difference was not found in terms of age group, sex, and experiences in participating in DNR decisions. Conclusion: Due to the positive attitude of doctors toward DNR orders and lack of identified guidance, clear guidelines that comply with the Iranian Islamic culture are necessary to be established. Implementing this directive requires comprehensive training to various groups, including patients, doctors, nurses, administrators, and policy makers of the health system. Keywords: cardiopulmonary resuscitation, physicians, attitude

Eiji Hiraoka,1 Yosuke Homma,2 Yasuhiro Norisue,3 Takaki Naito,1 Yuko Kataoka,1 Osamu Hamada,1 Yo Den,1 Osamu Takahashi,4 Shigeki Fujitani3 1Department of Internal Medicine, 2Department of Emergency Medicine, 3Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan; 4Department of Internal Medicine, StLuke’s International Hospital, Tokyo,Japan Background: Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures.Methods: A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated.Results: We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%).Conclusion: DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm. Keywords: code status, do-not-resuscitate order (DNR)

Given the poor results derived from cardio-pulmonary resuscitation (CPR), some decades ago, so-called do not resuscitate orders were established. These include unilateral medical decisions taken in extreme situations when the survival rate or recuperation of the patient is considered nil. Currently, and given the development of individual guaranties and their adoption in clinical practice, do not resuscitate orders are understood as agreements between physicians and patients (or their legal representatives) to not undertake CPR in the case of cardiac arrest. The definition of the clinical practice limits has slowly been accepted in view of the subsequent results in individuals’ lives. However, the compatibility of these decisions – considered restrictive – on patients who will be treated under anesthesia is not yet clear. The purpose of this article is to present a conceptual framework for this dilemma and to provide answers to the formulation, consequences, and implications of do not resuscitate orders in the perianesthesia period.

Objectives To explore the effect of the presence and timing of a do‐not‐resuscitate (DNR) order on short‐term clinical outcomes, including mortality. Design Retrospective cohort study with propensity score matching to enable direct comparison of DNR and no‐DNR groups. Setting Large, academic tertiary‐care center. Participants Hospitalized medical patients aged 65 and older. Measurements Primary outcome was in‐hospital mortality. Secondary outcomes included discharge disposition, length of stay, 30‐day readmission, restraints, bladder catheters, and bedrest order. Results Before propensity score matching, the DNR group (n=1,347) was significantly older (85.8 vs 79.6, p

Objectives: Cardiopulmonary resuscitation (CPR) is a life-saving procedure which may fail if applied unselectively. ‘Do not resuscitate’ (DNR) policies can help avoid futile life-saving attempts among terminally-ill patients. This study aimed to assess CPR outcomes and estimate healthcare costs in potential DNR cases. Methods: This retrospective study was carried out between March and June 2014 and included 50 adult cardiac arrest patients who had undergone CPR at Sultan Qaboos Hospital in Salalah, Oman. Medical records were reviewed and treating teams were consulted to determine DNR eligibility. The outcomes, clinical risk categories and associated healthcare costs of the DNR candidates were assessed. Results: Two-thirds of the potential DNR candidates were ≥60 years old. Eight patients (16%) were in a vegetative state, 39 (78%) had an irreversible terminal illness and 43 (86%) had a low likelihood of successful CPR. Most patients (72%) met multiple criteria for DNR eligibility. According to clinical risk categories, these patients had terminal malignancies (30%), recent massive strokes (16%), end-stage organ failure (30%) or were bed-bound (50%). Initial CPR was unsuccessful in 30 patients (60%); the remaining 20 patients (40%) were initially resuscitated but subsequently died, with 70% dying within 24 hours. These patients were ventilated for an average of 5.6 days, with four patients (20%) requiring >15 days of ventilation. The average healthcare cost per patient was USD $1,958.9. Conclusion: With careful assessment, potential DNR patients can be identified and futile CPR efforts avoided. Institutional DNR policies may help to reduce healthcare costs and improve services. Keywords: Cardiopulmonary Resuscitation; Medical Futility; Do Not Resuscitate Orders; Persistent Vegetative State; Terminally Ill; Healthcare Costs; Oman.

Although there are valid reasons to suspend do-not-resuscitate (DNR) orders during surgery, the decision to do so should be discussed with patients and should take into account their goals and objectives.

Many of our elderly have now signed advance directives or physicians' order sets of life-sustaining treatment forms. Frequently, choices have been made for no life-sustaining interventions at the end of life or do-not-resuscitate (DNR) orders. As the proportion of elderly grows and more patients seek surgical intervention for comfort or to improve their quality of life, the medical and ethical issues of DNR orders in the perioperative setting become increasingly more complex. Many health care providers neither recognize the complexity and significance of the DNR order during the perioperative period nor have hospitals established actions toward resolution of this situation. This article will discuss how this complex issue should be explored, definitions established, and positions recommended.

Aim Technological and clinical advances have reduced neonatal deaths, and this study explored how the mode and timing of neonatal deaths has changed in a tertiary neonatal intensive care unit (NICU) over 10 years. Methods We carried out a retrospective chart review on NICU deaths in 2000–2002 and 2007–2010, categorising deaths and compared the timing, cause and mode of death in the two cohorts. Results We analysed 204 neonatal deaths and found that the average age at death doubled from 9.71 days in 2000–2002 to 18.8 days (p = 0.014) in 2007–2010 and that the number of deaths in the first 48 h of life fell from 52% to 29% (p