A survey study conducted in Denmark showed that while nearly half of participating patients with cancer preferred early discussions related to do-not-resuscitate (DNR) decision making, less than one-fifth of physician respondents were in favor of that approach. These findings were published in Supportive Care in Cancer.
According to Danish law, physicians treating patients with a poor prognosis are obligated to consider the need for a DNR order. Furthermore, although physicians are required to involve competent patients in the decision-making process regarding a DNR decision, the final decision rests with them. This practice contrasts with the DNR decision-making process in North America, where patients, or their surrogates, are the final arbiters of whether a DNR order will be placed.
The main objective of this study was to use an 8-item, multiple-choice questionnaire to examine the attitudes and preferences of patients with cancer, their physicians, and nurses at an outpatient oncology clinic in Denmark regarding the DNR decision-making process.
Of the 1128 patients with cancer invited by their physician to complete the questionnaire, 908 (80%) agreed to participate in the study. Regarding physicians and nurses, 59 of 87 (68%) invited physicians, and 160 of 224 (71%) invited nurses completed a similar questionnaire. The questionnaires were completed in 2011, but data related to patient demographic characteristics, as well as disease- and treatment-related factors, and whether a DNR order was placed, were retrospectively abstracted from patient medical records 3 years later.
A key study finding was that 45%, 81%, and 76% of patients, physicians, and nurses, respectively, favored a collaborative DNR decision-making process that involved both the physician and the patient. However, in cases of disagreement between the patient and physicians, 67% of patients but only 10% of physicians selected the patient as the final DNR decision maker. In contrast, 31% of nurses selected the patient in this scenario. When queried about the most appropriate timing for a DNR-related discussion, 43% of patients and 36% of nurses selected “early in the course of disease,” but only 19% of physicians were in favor of this approach.
At 3 years following survey implementation, 45% of the study patients had died. DNR orders were in the medical records of approximately 83% of the patients who died while hospitalized, and a DNR decision-making conversation between patient and physician was documented for 60% of patients who died in or out of the hospital. The median time from DNR documentation until death was 10 days. However, the design of this study did not permit determination of the initiator of DNR-related discussions, whether final decisions regarding DNR order placement were shared, or the final arbiter of these decisions.
The study authors recommended that the Danish guidelines be revised to include thorough patient involvement. In addition, the guidelines should address questions regarding timing of the DNR discussion and how to resolve disagreements between patients and physicians.
Saltbæk L, Michelsen HM, Nelausen KM, et al. Cancer patients, physicians, and nurses differ in their attitudes toward the decisional role in do-not-resuscitate decision-making [published online April 15, 2020]. Support Care Cancer doi: 10.1007/s00520-020-05460-7