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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.

This case examines perioperative suspension of a do-not-resuscitate (DNR) order during surgery. The commentary considers the appropriateness of DNR orders; types of DNR order suspension in the context of alternative anesthesia techniques; and what is required from a surgeon, anesthesiologist, and patient or surrogate to reach a decision expressing the patient's best interest. It concludes by offering communication recommendations based on joint discussion and decision sharing.

Background and Objectives Performing cardiopulmonary resuscitation (CPR) on cardiac arrest patients with Do Not Resuscitate (DNR) orders does not respect patients’ autonomy. We aimed to 1) determine the frequency of patients who wished to be DNR prior to cardiac arrest; 2) determine what proportion received CPR; and 3) explain why DNR patients received CPR. Methods This was a retrospective chart review study of cardiac arrest patients at an emergency department. We reported the frequency and proportion of patients who 1) had valid DNR orders presented at the time of cardiac arrest; 2) had valid DNR orders that were unavailable at the time of arrest 3) had Advanced Directives but no DNR orders; 4) had their DNR orders rescinded; and 5) wished to be DNR but did not have any documents in place. Results Of 419 patients, 65 (15.51%) wished to be DNR. Out of these 65 patients, 38 (58.46 %) patients were resuscitated. Among the 38 patients, 23 (60.52%) received CPR accordingly and 15 (39.47%) patients were inappropriately resuscitated. Conclusion In our sample of 419 patients, 65 (15.51%) did not want CPR in the event of cardiac arrest and 38 (9.06%) received CPR against their wishes. This was due to failure to document DNR orders, lack of recognition of documented valid DNR orders, and use of non-actionable Advanced Directives to relay patients’ wishes.

Context Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited. Objectives To evaluate perioperative management of DNR orders at a tertiary care children's hospital. Methods We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period. Results Twenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point. Conclusion Opportunities exist to improve how DNR orders are managed during the perioperative period.

PURPOSE Issues related to life and death are largely influenced by the culture and religious beliefs of a society. This research aimed to survey a sample of oncology nurses in Saudi Arabia about their attitude towards the do not resuscitate order (DNR). METHOD A cross-sectional design was employed. A survey was sent to 190 nurses in the Comprehensive Cancer Center (CCC) in King Fahad Medical City (KFMC). A total of 157 nurses with a diploma or higher degree agreed to participate in the study. RESULTS Many nurses showed a neutral attitude regarding DNR to cancer patients and/or their families 2.4 ± 0.4. Moreover, the results of the multiple logistic regression tests revealed that all the listed factors are not associated with the attitude towards DNR orders (P > .05). CONCLUSION It is generally believed that nurses the faith and background of nurses from Muslim countries has a profound influence on their attitude towards DNR. However, this was not the picture that was revealed by the results of this study. In this study, all the nurses made it clear that they wanted to know about the autonomy of patients in respect of DNR orders. IMPLICATION TO CLINICAL PRACTICE It is necessary to develop programmes that address the DNR order and respect patient autonomy and rights. Moreover, hospital policies that address the issues of DNR order are required for all end-of-life care.

BackgroundDo-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists.MethodsWe performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model.ResultsA total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant.ConclusionsThe use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

Cardio-pulmonary resuscitation (CPR) is often shortened to “resuscitation” and refers to emergency procedures to maintain circulation when the heart has stopped beating and the lungs are struggling to work. It is often enough to restart the heart by applying chest compressions and to restore lung function by artificial ventilation thus maintaining circulatory flow and oxygenation during cardiac arrest. The word “revival” is used for “resuscitation” in Latin countries.

Background: End-of-life treatment decisions present special challenges for prehospital emergency providers. Paramedics regularly make value-laden choices that transcend technical judgment and professional skill, affecting the type of care, how and to whom it is provided. Changes in prehospital emergency care over the last decade have created new moral challenges for prehospital emergency providers; these changes have also accentuated the need for paramedics to make rapid and reasoned ethical judgments. Objective: The purpose of the study was to explore the decision-making process that occurs when prehospital emergency teams respond to an end-of-life call with a focus on how state authorized documents such as a Non-Hospital Do Not Resuscitate (NHDNR) or Medical/Physician���s Orders for Life-Sustaining Treatment (MOLST/POLST) or lack thereof inform decision-making. This paper presents the specific circumstances that informed the need for intervention from Online Medical Direction (OLMD) framed in the perspectives and words of the prehospital providers seeking that assistance. Methods: This study involved in-depth in-person interviews with 50 providers to elicit participants��� experiences in their own words using a semi-structured interview instrument. Interviews were audio recorded and transcribed with permission. Results: Five themes emerged that illuminated how and when OLMD was involved in emergency end-of-life decisions: Termination of Resuscitation (TOR); Family Revoked DNR; Missing Documents; No Documents and No CPR; and Unusual Situations. Participants illustrated how the decision to terminate efforts was best-supported when it was made by collaboration between the on-scene provider and OLMD. Participants described ethical dilemmas when families asked them to initiate CPR in the presence of DNR orders and cognitive dissonance when CPR has been initiated but a valid DNR/MOLST is subsequently located. Conclusions: The study findings demonstrate the invaluable contribution of OLMD for complex end-of-life care decisions by prehospital providers, especially when there are difficult legal, ethical, and logistical questions. OLMD provides far more than technical support.

Some care home residents were wrongly subjected to decisions ruling out attempts at cardiopulmonary resuscitation (CPR) in the early stages of the covid-19 pandemic, leading to potentially avoidable deaths, the Care Quality Commission (CQC) has concluded.1 Advance instructions not to attempt CPR should a patient’s heart or breathing stop in future should be discussed with patients, if they have the capacity to consent, or with their family, and made on an individual basis. But amid fears that hospitals would be overwhelmed with covid-19 …

Hospitalized patients with do-not-resuscitate (DNR) orders commonly require surgical procedures. When this occurs, the usual practice in our medical center is to suspend the DNR order during the perioperative period. Few studies provide the patient perspective regarding automatic DNR suspension. The research team used a mixed-method, nonexperimental qualitative study design to conduct audio-recorded interviews with 17 nonsurgical patients who had DNR orders. We studied the patients' understanding of DNR status and their expectations regarding the changing of this status if surgery were required. The patients in the study expected a discussion regarding any change in their DNR status before the day of surgery and thought they should have the option to maintain their DNR status.

Introduction and Objective: The do not resuscitate (DNR) order is a decision taken by the patient or other people about medical care in the end stages of life to prevent resuscitation from causing cardiac or respiratory arrest. This study was conducted to evaluate the attitudes of patients' relatives in the end stages about DNR order. Materials and Methods: In a cross-sectional study, 150 relatives of patients who had been prescribed DNR orders were included in the educational hospitals affiliated to the Kermanshah University of Medical Sciences. The data collection tool was a researcher-developed questionnaire consisting of 29 attitudes questions related to DNR orders. The data were collected and analyzed in the SPSS software version 19 using descriptive tests. Results: According to the results of present study, although the relatives of pationts consider doctors thoroughly responsible for making decision related with DNR, and follow their order either way, they strongly disagree with a single doctor making individual decision in this domain. They believe that the patient and their relatives should be engaged in this decision. Although most participants tended to stay as close as possible to the patients and engage in patient care. Conclusion: Given that there are a few studies in Iran on the attitudes of patients and their relatives about DNR, and there are no specific rules and guidelines in this regard. It is recommended that further studies be conducted on the subject. Engaging of patients and families in this important decision is necessary.

Policies addressing limitations of medical therapy in patients with advanced medical conditions are typically referred to as Code Status (No Code) policies or Do-Not-Resuscitate (DNR) status polices. Inconsistencies in implementation, understanding, decision-making, communication and management of No Code or DNR orders have led to delivery of poorer care to some patients. Several experts have called for a change in the current approach. The new approach, Goals of Care paradigm, aims to contextualize the decisions about resuscitation and advanced life support within the overall plan of care, focusing on choices of treatments to be given rather than specifically on treatments not to be given. Adopting “Goals of Care” paradigm is a big step forward on the journey for optimizing the care for patients with advanced medical conditions; a journey that requires collaborative approach and is of high importance for patients, community and healthcare systems.

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: Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders. Patients and Methods: Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling. Results: At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036–4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989–89.786; P=.008). Both arms issued DNR orders close to death (median, 5–6 days before death). Conclusions: Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846

Explore surgical options within the context of goals of care in an elderly woman with end stage COPD who presents with a cecal volvulus. The surgeon guides us through discussions about whether or not to pursue surgery, if and for how long to rescind the DNR, how to deal with the inevitable complications and final decline of the patient, how to support colleagues, how to prognosticate, and how to use best-case/worst-case scenarios.

The Do-Not-Resuscitate (DNR) directive has provided a major leap in end-of-life care. To demonstrate the factors influencing physicians’ DNR decisions in King Fahd University Hospital in the Eastern Province of Saudi Arabia, 42 physicians from the medical and surgical departments of the same center were requested to participate in a cross-sectional survey. Thirty-six questionnaires were completed and returned from a total of 42 distributed among physicians, making a response rate of 85.7%. Certain diagnostic categories increase the likelihood of issuing a DNR order for a patient. Neurological (58.3%) and cardiovascular (41.7%) diseases were the highest response among other diseases in influencing physicians’ decisions. In addition, other factors like lack of comorbidities (55.5%), age (52.7%), and previous intensive care unit (ICU) admissions and resuscitation (44.4%) showed an effect on the directive decisions of DNR among investigated physicians. However, weak palliative care in the hospital (11.1%), religious beliefs (5.5%), and gender (2.7%) were the least associated factors affecting physicians’ DNR decisions. This study addresses the influencing factors of DNR orders issuance among King Fahd Hospital of the University physicians. Physicians noted that cultural standards and religious beliefs do play a role in their decision-making but had less of an effect as compared to other clinical data such as comorbidities, age, and previous ICU admissions.

Aim: The decision-making process for do-not-resuscitate (DNR) order has always been challenging. Cultural and religious issues have limited the issuance and execution of DNR orders in Iran. The purpose of this study was to assess the attitude of the nurses, physicians, patients, and their families toward the DNR order. Subjects and Methods: In this cross-sectional study, 343 participants (201 patients, 95 family members, and 47 healthcare providers) from Omid Oncology Hospital, Mashhad, Iran, were surveyed during 2017–2018. All the participants were asked to fill in a checklist of demographic information and a validated questionnaire about their attitude toward DNR orders after giving consent. The data were analyzed using SPSS software and values of P < 0.05 were considered statistically significant. Results: Overall, 201 patients and 95 of their family members, as well as 47 healthcare providers (doctors and nurses), were surveyed. The mean age of participants was 48.75 ± 15.62 years. The attitude of the participants regarding the DNR order was significantly different in 10 of the 11 items (P ≤ 0.005). Among the three groups of participants, healthcare providers showed the most positive attitude regarding the DNR order. The attitude of participants regarding the DNR orders was significantly associated with age, occupation status, residential place, educational status, and income level (P < 0.05). Conclusions: Various factors, such as economic status, level of education, place of residence, and gender, can be effective on decision-making regarding the DNR orders. Unified and sustained education regarding moral and cultural issues can be helpful in the reconciliation of the attitudes between caregivers and patients.

The aims of this study were to investigate the reasons of transfers from long-term care hospitals (LTCHs) to emergency departments (EDs) of university hospitals in geriatric patients and to categorize the avoidable causes of these transfers. This retrospective multicenter study involved patients aged 65 years and older who were transferred from LTCHs to 5 EDs of university hospitals located in the metropolitan area of South Korea between January 2017 and December 2017. The expert panel reviewed and categorized the reason of transfers as avoidable or not. Moreover, we also investigated the number of patients with do-not-resuscitate (DNR) documents and the date these DNR documents were written. A total of 255,543 patients visited 5 EDs during the study period. Of these, 1,131 patients were from LTCHs. The number of potentially avoidable transfers was 168/1,131 (14.9%). The most common reason of avoidable transfers was noncritical diagnoses that could be assessed and managed in LTCHs (57.1%). There were 162 patients with DNR orders; of these, 12 had approved the DNR order before transfer. In conclusion, in Korea, potentially avoidable transfers could be reduced by managing noncritical diseases in LTCH and preparing advance care directives, including DNR orders, during admission to LTCH.

Background and Aims This study aims to assess current practices and perspectives of gastroenterologists on approaches to code status before inpatient endoscopy. Methods Self-reported data were obtained through a voluntary, anonymous survey of gastroenterologists and gastroenterology trainees in the United States (U.S.). The survey assessed respondents’ approach to, beliefs, and knowledge regarding inpatient periprocedural code status discussions. Results Four hundred thirty-six gastroenterologists and 83 trainees completed the survey. In patients with an existing do not resuscitate (DNR) order, respondents reversed the code status before endoscopy either all (40.8%, n = 212) or most of the time (18.3%, n = 95). When asked their personal opinion, 32.6% (n =169) supported automatic DNR reversal to full resuscitation attempt during a procedure, 18.5% (n = 96) supported that DNR orders could be sustained, and 48.7% (n = 253) supported offering limited resuscitation. Many gastroenterologists were unaware of institutional (40.7%, n = 211) or national (80.7%, n = 419) policies and a majority reported that a gastroenterology-specific guideline would be helpful (88.6%, n = 460). Conclusions Although the majority of gastroenterologists reverse DNR orders more than 75% of the time before endoscopy, many also believe patients should be allowed to remain DNR during a procedure and supported a third option for limited resuscitation. Most gastroenterologists were unaware of institutional policies or existing national guidelines. These findings suggest considerable variation in knowledge and current approaches regarding periendoscopic code status reversal.

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.

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)

Do-not-resuscitate (DNR) orders reflect an important means of respecting patient autonomy while minimizing the risk of nonbeneficial interventions. We sought to clarify trends and differences in rates of DNR orders for patients hospitalized with heart failure.We used statewide data from California's Healthcare Cost and Utilization dataset (2007-2010) to determine trends in DNR orders within 24 hours of admission for patients with a primary discharge diagnosis of heart failure.Among 347,541 hospitalizations for heart failure, the rate of DNR order within 24 hours increased from 10.4% in 2007 to 11.3% in 2010 (P.0001). After adjustment, DNR status correlated with older age, female gender, white race, frequent comorbidities (Charlson Score), and residence in higher income area (P .0001). DNR use was more likely in hospitals with public or nonprofit financing or medical school affiliation, but not being a member of the Council on Teaching Hospitals (all P .001).DNR order use among inpatients with heart failure is low but increasing slowly and varies by patient demographics and hospital characteristics.

The primary goal of this article is to improve end-of-life (EOL) care in the perioperative period. Clinicians should be able to understand the ethical and legal foundations for the "do-not-resuscitate" (DNR) order to help patients and their families make decisions about EOL care, understand the concept of "required reconsideration" for DNR orders prior to surgical procedures, acknowledge that DNR orders are based either on the patient's perception of their quality of life (QOL) or the physician's determination of medical futility as it relates to the patient's disease process, and appreciate the distinction between prolonging life and prolonging death in the perioperative setting.

RESEARCH OBJECTIVE: The Center for Medicare and Medicaid Services (CMS) publishes measures of risk‐adjusted hospital mortality rates that are meant to guide consumers and to contribute to Value‐Based Payment (VBP) quality ratings used to redistribute up to $2 billion in Medicare payments annually. A hospital’s actual to expected (A/E) mortality ratio accounts for 25% of its VPB rating. Current risk adjustment for mortality rates includes previously coded comorbidities and complications (CCs) but does not include indicators of higher mortality risk such as Do Not Resuscitate (DNR) orders present on admission (POA). We examined whether hospital mortality ratings could be improved by allowing DNR orders that are POA to identify a high‐risk group of patients among the 3 CMS mortality cohorts: acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN). STUDY DESIGN: We created a risk‐adjusted ranking of hospitals with and without admissions that had a DNR code POA using the All‐Patient Refined Diagnosis Risk Group Risk of Mortality (APR DRG RoM) at admission for the VBP cohorts. We computed the ratio of deaths to admissions for each DRG and ROM level for the 3 VBP cohorts as well as for all hospital admissions for the year. These ratios provided an expected rate of mortality for every admission through indirect rate standardization. For the 3 mortality rate cohorts, we calculated independent A/E mortality ratios for each hospital using existing CMS cohort definitions. We then repeated the calculation excluding admissions where DNR was reported as POA. We ranked the hospitals by A/E mortality rates and examined the change in decile ranks with and without DNR POA cases. POPULATION STUDIED: We used data for calendar year 2016 (CY2016) from the CMS Fee‐for‐Service (FFS) claims file for diagnosis codes and DNR status and used the Medicare Master Beneficiary Summary File (MBSF) to identify all deaths within 30 days of hospital admission. Among a total hospitalized population of 8.21 million with a death rate of 8.2%, there were 1.032 million admissions from the 3 VBP cohorts, of whom 14.2% had a DNR order POA and 11.3% died. PRINCIPAL FINDINGS: Unsurprisingly, the presence of a DNR order POA was associated with a much higher risk of 30‐day mortality. Overall, death rate for the mortality cohorts with DNR POA was 29.7%, compared to 8.2% without. For the entire hospitalized population, death rate was 30.3% with a DNR order POA, and 5.8% without. With the removal of DNR POA patients, hospital A/E mortality rankings changed substantially. 70% of hospitals moved up or down by at least one decile, and 34% moved up or down by 2 or more deciles. CONCLUSIONS: The DNR POA order identifies patients at higher risk of death and can thereby alter VBP hospital mortality rate rankings and the resulting payment redistributions. IMPLICATIONS FOR POLICY OR PRACTICE: If the purpose of scrutinizing mortality rates is to identify preventable deaths, then continuing to include patients whose goals of care include DNR status can distort the risk‐adjustment process. The CMS mortality model should include adjustments for patients with DNR POA orders or remove them from the analysis entirely.

Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients ( P < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; P < 0.001) and ICU length of stay (7.72 days; P < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.

OBJECTIVE: To evaluate the etiology and discharge outcome of non-traumatic intracerebral hemorrhage (ICH) in young adults admitted to a comprehensive stroke center. METHODS: A retrospective chart review was performed on patients with a discharge diagnosis of non-traumatic ICH admitted from 7/1/2011 to 6/30/2016. Data was collected on demographics, clinical history, ICH score, hemorrhage location, do-not-resuscitate (DNR) orders, likely etiology, and discharge disposition. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH, and ICH score with the discharge outcome. RESULTS: Sixty-three patients met the study criteria, with mean age 35.4 ± 6.4 years including 26 (41%) women and 40 (64%) whites. Headache (65%) and change in mental status (48%) were the most common presenting symptoms. Hemorrhage was most commonly seen in the deep structures in 29 (46%) patients followed by lobar ICH in 14 (22%) patients. The most common etiology of ICH was hypertension in 23 (37%) patients, followed by vascular abnormalities in 18 (29%) patients. Forty-two (67%) had good outcome defined as discharge to home (n=25) or acute inpatient rehabilitation (n=17). Twenty-one (33%) patients had bad outcome with discharge to skilled nursing facility (n=6), hospice (n=1) or died in the hospital (n=14). Hospital DNR orders were noted in 11 (18%) patients. Higher ICH score (p

BACKGROUND:Patients treated at 24/7 percutaneous coronary intervention (PCI) centres following out-of-hospital cardiac arrest (OHCA) have better outcomes than those treated at non-24/7 PCI centres. However, variation in outcomes between 24/7 PCI centres is not well studied. OBJECTIVES:To evaluate variation in outcomes among 24/7 PCI centres and to assess stability of 24/7 PCI centre performance. METHODS:Adult patients in the California Office of Statewide Health Planning and Development Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest admitted to a 24/7 PCI centre from 2011 to 2015 were included. Primary outcome was good neurologic recovery at hospital discharge. Secondary outcomes were survival to hospital discharge, cardiac catheterisation, and DNR orders within 24 h. Data were analysed using mixed effects logistic regression models. Hospitals were ranked each year and overall. RESULTS:Of 27,122 patients admitted to 128 24/7 PCI centres, 41%25 (11,184) survived and 27%25 (7188) had good neurologic recovery. Adjusted rates of good neurologic recovery (18%25-39%25; p,0.001), survival (32%25-51%25; p

Background The present study aimed to characterize factors associated with patients issued DNR orders during hospitalization who are discharged alive without any instruction orders by physicians regarding end-of-life treatment, with a focus on the timing of DNR order issuance. Methods In total, 2997 DNR cases from all 61,037 patients aged ≥20 years admitted to a representative general hospital in Tokyo were extracted and divided into two groups by patient hospital release status (discharged alive/deceased). Study items included age, sex, disease type (non-cancer/cancer), hospital department (internal medicine/others), timing of DNR order issuance, implementation (or not) of life-sustaining treatment (LST) or the presence of any restrictions on LST and hospital length of stay. We conducted multiple logistic regression analysis, setting hospital release status as the dependent variable and each above study item as explanatory variables. Results DNR orders were issued at a rate of 4.9%. The analysis revealed that patients with a DNR who were ultimately discharged alive were statistically more likely to be those for whom DNR orders are issued early after admission (adjusted odds ratio: AOR, 13.7), non-cancer patients (AOR, 3.4), internal medicine department patients (AOR, 1.63), females (AOR, 1.34), and elderly (aged ≥85 years; AOR, 1.02); these patients were also less likely to be receiving LST (AOR, 0.36). Conclusions By focusing on those with DNR orders who were ultimately discharged alive, we discovered that these patients were likely to have DNR orders issued early after admission, and that they were more likely to be elderly, female, non-cancer patients, or those in internal medicine departments. Further examination of these data may help to elucidate why these particular DNR-related characteristics (including socio-economic and cultural factors) are evident in patients who end up being discharged alive.

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

Objective: Hospital physicians in Sweden most often decide do-not-resuscitate orders (DNR) without collaboration. Systematic pre-arrest indicators of cardiopulmonary resuscitation (CPR) do not exist. Therefore, new, and for the first time, national ethical guidelines on CPR have recently been published in Sweden. We aimed primarily to investigate if doctors and nurses knew about the guidelines and thereafter to gauge their attitudes concerning DNR. Methods: An anonymous questionnaire was conducted of 48 doctors and 45 nurses (n=93) at surgical, medical and geriatric clinics at Orebro University Hospital, Sweden. A response rate of 62% was achieved. The questionnaire contained 17 questions; four about background information and 13 questions about procedures concerning DNR-orders where responses "yes, always", "normally", "seldom", "no, never" and "don't know" were most often available. Respondents were also invited to leave explanatory remarks. Results: Eighty percent of doctors knew about the new ethical guidelines, in contrast to 42% of nurses. Twenty-seven percent of doctors discussed with patients DNR-orders "normally", though 31% did it "seldom". Whereas nurses did this either "seldom" (40%) or "never" (58%). Ninety-one percent of nurses were in favour of patient involvement in decision-making concerning DNR-orders. Conclusion: While a moderate level of knowledge of the ethical guidelines existed, especially in doctors, the present study highlights a possible discrepancy between the awareness of the guidelines with the prevailing hospital praxis and the general attitudes of respondents. The study questions to what extent the guidelines are in fact implemented. Greater involvement of nurses, other paramedic staff and patients may lead to improve in-hospital patient care. Further descriptive and qualitative studies would be useful to explore these issues.

Background: Do not resuscitate (DNR) orders are put in place where cardiopulmonary resuscitation is inappropriate. However, it is unclear who should be involved in discussions and decisions around DNR orders. Aim: The aim was to determine the views of oncology and palliative care doctors and nurses on DNR orders. Materials and Methods: A questionnaire survey was conducted on 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer center in Singapore. Results: Perceived care differences as a result of DNR determinations led to 50.7% of respondents reporting concerns that a DNR order would mean that the patient received a substandard level of care. On the matter of DNR discussions, majority thought that patients (78.8%) and the next of kin (78.1%) should be involved though with whom the ultimate decision lay differed. There was also a wide range of views on the most appropriate time to have a DNR discussion. Conclusions: From the viewpoint of oncology and palliative care healthcare professionals, patients should be involved at least in discussing if not in the determination of DNR orders, challenging the norm of familial determination in the Asian context. The varied responses highlight the complexity of decision making on issues relating to the end of life. Thus, it is important to take into account the innumerable bio-psychosocial, practical, and ethical factors that are involved within such deliberations.

A few weeks ago, Texas took an unprecedented position on unilateral DNRs by passing Senate Bill (SB) 11, which requires patient/surrogate consent for writing DNR orders. The motivation behind the bill was based on the drafters' beliefs that physicians frequently write unilateral DNR orders. SB 11, however, does not stop at requiring physicians to seek consent for DNR orders. Instead, the legislation uncharacteristically exceeds what is typically within the scope and role boundaries for lawmakers by legislating how physicians discuss and implement DNR orders. We contend that this bill is ethically problematic and will have far-reaching, negative consequences that will affect how critical care medicine is practiced. In what follows, we describe how proponents' arguments rely on several ethical assumptions, and we describe potential negative impacts stemming from this legislation. Finally, we offer an alternative approach that would mitigate proponents' concerns. We believe SB 11 and our analytic deconstruction of it should serve as "lessons learned" for other states considering similar legislation.

Aim: Do not resuscitate (DNR) is an order in medical practice for the patients who are suffering from a grave medical condition, and their life is in danger to end. DNR decision-making varies from one hospital to another. This study is aimed to assess the knowledge of the patients' relatives about DNR concept and their opinion about the DNR decision-making. Materials and Methods: This was a nonintervention cross-sectional study conducted, during 2016, among 420 patients' relatives in the Emergency Department at King Abdul-Aziz University Hospital in KSA. Data were collected by interviewing the participants. Data were further analyzed using SPSS software. The Chi-square test was used to determine the associations. Results: Variation in responses related to the DNR concept was observed. Around 44% of participants thought that DNR involved maximum intervention in the hospital, including intensive care. Further, the majority (55.2%) of the participants were assured about the quality of the services the patient would receive. Furthermore, 51% of the participants believed that ultimately, it should always be the doctor who decides on a DNR decision. Meanwhile, 36.4% of the relatives opined that the family members should be involved in the discussion regarding the DNR order. Conclusion: We observed a gap in the understanding of the concept and decision-making of DNR-order among the participants. Health-care providers should provide a greater explanation about DNR orders to the families of the patients to avoid any misunderstandings, and also support them psychologically to avoid any stress they might encounter in such situations.

BACKGROUND: We evaluated the clinical characteristics and factors associated with mortality in very elderly patients ≥ 90 y of age admitted to the ICU. METHODS: We evaluated age-specific rates of admission and mortality in 16,935 subjects ≥ 18 y old and retrospectively analyzed the clinical data of 155 (0.92%) subjects ≥ 90 y old admitted to the ICU from January 2003 to July 2012. The clinical mortality index was defined as the ICU mortality rate associated with clinical risk factors including poor nutrition, do not resuscitate (DNR) order, pneumonia, chronic renal failure, cancer, mechanical ventilation, use of a vasopressor, and admission from a ward. RESULTS: The mortality rate of ICU subjects ≥ 90 y of age was 32.3%. A Cox's regression hazard model revealed that high glucose ( P = .006), poor nutrition ( P = .001), high Simplified Acute Physiology Scoring II scores ( P < .001), DNR order ( P = .002), and vasopressor treatment ( P = .03) were independent predictive factors of mortality in subjects ≥ 90 y of age admitted to the ICU. An increasing number of clinical risk factors was associated with progressively higher mortality rates. All subjects with more than 5 risk factors died. CONCLUSIONS: The very elderly subjects (≥ 90 y) admitted to the ICU had a higher mortality rate compared with subjects of other ages. High Simplified Acute Physiology Scoring II scores, poor nutritional status, high glucose, use of vasopressors, and DNR orders should be considered as important predictors of mortality in very elderly ICU patients. The level of ICU treatment should be carefully considered in very elderly patients presenting with 5 or more risk factors.

The purpose of this study was to compare and analyse attitudes towards death and perceptions of do-not-resuscitate (DNR) orders between the elderly living in a facility and those living at home, in order to provide basic data for effective nursing interventions to help the elderly prepare for death in a positive manner. The subjects of this study were 300 persons over 65 years old who lived in a facility or home in Seoul or Gyeonggi Province, South Korea, and data were collected from 1 April to 15 August 2012. Descriptive analysis, χ(2)-test, and ANCOVA were conducted on the data using the SPSS version 20.0 program. With regard to attitudes towards death, the elderly in a facility reported that physical pain relief was most necessary for a comfortable death, and the elderly living at home reported that psychological stability was most required. With regard to perceptions of DNR orders, most of the participants agreed that DNR is sometimes necessary (institution: 86.7%, home: 78.7%). About 8% more of the elderly living in a facility considered DNR to sometimes be necessary compared with the elderly living at home. In conclusion, the elderly living in a facility were interested in physical pain relief or physical health, and the elderly living at home were focused on psychological stability or psychological health. Based on the findings, basic data for development of effective nursing interventions to help the elderly prepare for death in a positive manner can be provided.

Purpose The purpose of this systematic review is to assess if Do Not Resuscitate (DNR) orders should be routinely rescinded during anesthesia, determine if consensus on retaining DNR orders exists in the literature, and explore the current state of clinical practice. Design This systematic review followed preferred reporting items for systematic reviews and meta-analyses guidelines. Methods In June 2018, the Cumulative Index to Nursing and Allied Health Literature and PubMed databases were systematically searched using defined inclusion/exclusion criteria. Findings Ninety-one articles from the databases were pooled with 16 works identified as formative to the research questions. Forty-nine articles were analyzed and included in this study. Conclusions It is unethical to automatically rescind DNR orders during anesthesia. Patients have the right to retain their DNR orders unaltered or modify them for the perianesthesia period. Sufficient evidence exists to create meaningful policy at every level. A consensus exists among professional organizations that the standard of care is a required reconsideration of DNR orders before anesthesia.

International audience; BackgroundThe “Do Not Resuscitate” orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients.MethodsA systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: “resuscitation orders” OR “do-not-resuscitate” combined with “aged, 80 and over” combined with “comorbidities” OR “chronic diseases”.ResultsOf the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19–1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07–1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08–3.20) for cancer, OR=1.07 (95% CI: 0.92–1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61–2.40) for stroke.ConclusionsThis systematic review and metaanalysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.

Do-not-resuscitate (DNR) orders are an important part of advance directives. To date, little is known about DNR orders in Ontario's long-term care (LTC) facilities. The Canadian Institute for Health Information (CIHI) stated that in between 2011 and 2012, there were more than 32,000 discharges from Ontario's LTC facilities, 44% of which resulted from death. This study examined DNR orders in LTC homes in Ontario. The sample includes all LTC residents receiving care between 2010 and 2012. Data provided by the CIHI were collected using the Canadian version of the Resident Assessment Instrument. The data included administrative assessments on health of 112,746 residents. The average age of LTC residents in this study was 84.5 years, and about 70% were female residents. Results showed that residents admitted from home were less likely to have a DNR order on file during assessment and three months later. Residents whose families were responsible for care were more likely to have DNR orders when admitted, but this effect was not found at three-month follow-up. Residents who were in end-stage diseases were more likely to have completed DNR orders upon admission to LTC facilities. The presence of a health condition (eg frailty, depression, heart condition, pulmonary or psychiatric condition) increased the likelihood of residents having DNR orders when admitted to LTC facilities. Residents whose conditions were deteriorating were more likely to have completed DNR orders before the three-month follow-up. In conclusion, this study represents an important step in identifying issues related to DNR orders in LTC facilities. The factors that influence whether residents have DNR orders on file upon admission depend on the presence of family members, whether the residents are designated as end-of-life cases (six months or less), older age, and health. Discussions about resuscitation are an important part of care plans.

Elderly patients who have preexisting DNR orders experience a high incidence of mortality and major morbidity within 30 days after emergency general surgery. Although not a risk factor for major morbidity, preoperative DNR status does represent an independent risk factor for mortality after emergency general surgery. The most plausible reason for the excess mortality in DNR patients is their decreased willingness to undergo aggressive treatment of major postoperative complications. Whether patient-driven failure-to-pursue-rescue also explains to some extent the high mortality of non-DNR elderly emergency general surgery patients deserves further investigation.

Background The influence of socio-economic and religious background on decisions made by parents of children with incurable cancer regarding DNR orders is not fully understood. Procedure A retrospective analysis of medical charts of patients who died between January 2000 and January 2011 was performed. The following data were sought: written evidence of DNR discussion with parents, religious background, educational level, monthly income. Results There was evidence of a discussion on DNR in 73/90 charts. DNR consent was obtained in 14/17 (82.4%) cases where at least one parent had >15 years of education versus in only 24/45 (53.3%) cases where both parents had ≤15 years education as determined by univariate analysis (P = 0.03). DNR consent was also more likely to be obtained among parents of children with income >10,000 NIS (24/30, 80.0% vs. 20/38, 52.6%, P = 0.013). Parents of Jewish (22/30, 73.3%), Islamic (16/26, 61.5%), and Christian (8/9, 88.9%) background were equally likely to provide DNR consent. However, Druze families were less likely to do so (2/8, 25.0%, P = 0.036). Conclusions The process of decision-making to a DNR request was associated with parents' educational level and monthly family income, and not by religious background, with the exception of Druze families. Pediatr Blood Cancer 2014;61:265–268. © 2013 Wiley Periodicals, Inc.

Background: There is growing awareness of the need for advanced care planning in patients with COPD. The appropriate moment to discuss DNR orders in these patients remains a difficult clinical decision. Aims and objectives: To evaluate the use and time point of DNR orders as part of advanced care planning in COPD patients in a tertiary care centre in Belgium. Methods: Retrospective analysis of patient files of 569 COPD patients with a median follow-up (FU) of years (median + IQR). Results: 30 patients were excluded for undergoing lung transplantation or lost to FU. 345 patients received no DNR order, of whom 94 (27%) died (median FU 2557 days). 194 patients received a DNR order, of whom 149 (82%) died (median FU 2583 days). Patients with DNR had lower FEV1 (44% pred. vs. 56% pred.). Median time between first DNR order and death was 163 days; 28% and 43% died within 30 days and 90 days, respectively. 50% died in hospital; 12% died in the ICU or ER. Most frequent DNR order was 9no CPR and no intubation9 (40%); most frequent motivation was 9poor respiratory status9 (65%). The majority (86%) of DNR orders were written during hospitalization, of which 20% in the ICU or ER. Only 19 out of 539 patients (4%) got DNR orders during outpatient visits. Conclusions: COPD patients receiving a DNR order have a high probability of dying. The majority of DNR orders is made during hospitalization, with only 4% during stable conditions in ambulatory FU. These data are reflecting the difficulties with advanced care planning in COPD.

End-of-life decisions and advance directives require timely physician-patient discussions but barriers exist to these discussions.To evaluate the influence of physician and patient gender on the timing of inpatient do-not-resuscitate (DNR) orders.Retrospective cohort study.All adult patients (≥18 years) with cancer who received inpatient DNR orders at The University of Texas MD Anderson Cancer Center between January 2011 and December 2013.Gender interaction between physicians and patients towards timing of the DNR order.We identified 4,157 unique patients with a cancer diagnosis. These patients were treated by 353 physicians, of whom 123 (34.8%) were females and 230 (65.2%) were males. Multivariate analysis showed female patients were 1.3 times more likely to have early DNR orders written during hospital admission than were male patients (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.07-1.50). When comparing gender interaction between physicians and patients, our results showed that female physicians were 1.5 times more likely to write early DNR orders with their female patients than for their male patients (OR, 1.48; 95% CI, 1.13-1.94). Same gender physician-patient dyads were not found between male physician and their patients (OR, 1.09; 95% CI, 0.91-1.31). Higher age, more comorbid conditions, and progression of diseases were also associated with early DNR orders (all p 0.01).Female patients are more likely to receive early DNR orders from their female physicians. Gender and gender interaction between physician and patients may potentially influence the timing of receiving DNR order.

Aim: Most analyses of end of life decisions in Neonatal Intensive Care Units (NICUs) have come from Europe ⁄ English-speaking countries. Would decisions be different in Latin American NICUs? Therefore, we aim to evaluate the approach to dying infants ⁄ families in NICUs in Latin America. Methods: Multinational descriptive study of all deaths in babies born at >22 weeks in eight NICUs in five Latin American countries. Deaths were categorized as: (i) no Cardiopulmonary Resuscitation (CPR) or life support offered; (ii) life support initiated but do not resuscitate (DNR) orders written or no CPR provided; (iii) full life support and CPR; and (iv) unclassifiable. Results: There were 100 deaths, 81% in >27 weeks. Seventeen infants received no CPR ⁄ life support at birth, 10 died in DR and seven in NICU. There were 27 infants in group 2, 54 in group three and two in group 4. No baby had care withdrawn or care withdrawn ⁄ CPR withheld. Thirty-two infants had ‘do not resuscitate’ order. Decisions without parents’ involvement in 15%, both parents present at death 24% and sedatives ⁄ narcotics documented 14%. Conclusions: Latin American NICUs differ from those in Northern Europe ⁄ Englishspeaking countries. More deaths are accompanied by full life support and CPR. DNR orders are rare. Withdrawal of life support is virtually non-existent. Latin American’s doctors are more likely to make decisions without the objections of family about withholding life-sustaining treatment.

Abstract In medical practice in Germany and several other countries abbreviated orders linked to end-of-life decisions, such as DNR (do not resuscitate), are increasingly used. In order to investigate their legal status, this article gives an overview of the recently passed German law, which regulates the process of end-of-life decision-making and the use of living wills, giving primacy to patient autonomy. Concerning the risk of misinterpretation of acronyms, the article describes the impacts of such orders on patient autonomy and safety and suggests a clear systematic classification of the different DNR orders in order to investigate their legal status under the German law. Their general binding force is to be acknowledged, depending on its origination and the fulfilment of certain requirements.