How do medical residents discuss resuscitation with patients?
Purchase on Springer.com
$39.95 / €34.95 / £29.95*
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.
OBJECTIVE: To describe how medical residents discuss do-not-resuscitate (DNR) orders with patients.
DESIGN: Prospective observational study.
SETTING: Inpatient medical wards of one university tertiary care center, one urban city public hospital, and one Veterans Affairs medical center.
PARTICIPANTS: Thirty-one medical residents self-selected 31 of their English-speaking, competent patients, with whom they had DNR discussions.
MEASUREMENTS: Three independent observers rated audiotaped discussions about DNR orders between the medical residents and their patients. Ratings assessed whether the physicians met standard criteria for requesting informed consent (e.g., disclosed the nature, benefits, risks, and outcomes), addressed the patients’ values, and attended to the patients’ emotional concerns.
MAIN RESULTS: The physicians often did not provide essential information about cardiopulmonary resuscitation (CPR). While all the physicians mentioned mechanical ventilation, only 55% mentioned chest compressions and 32% mentioned intensive care. Only 13% of the physicians mentioned the patient’s likelihood of survival after CPR, and no physician used a numerical estimate. The discussions lasted a median of 10 minutes and were dominated in speaking time by the physicians. The physicians initiated discussions about the patients’ personal values and goals of care in 10% of the cases, and missed opportunities to do so.
CONCLUSIONS: Medical ethicists, professional societies, and the public recommend more frequent discussions about DNR orders. Even when housestaff discuss resuscitation with patients, they may not be accomplishing the goal of increasing patient autonomy. Research and education must focus on improving the quality, as well as the quantity, of these discussions.
- ACP Ethics Subcommittee. American College of Physicians ethics manual. Third edition. Ann Intern Med. 1992;117:947–60.
- American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care, VIII: ethical considerations in resuscitation. JAMA. 1992;268:2282–8. CrossRef
- American Thoracic Society. Withholding and withdrawing life-sustaining therapy. Ann Intern Med. 1991;115:478–85.
- Council on Ethical and Judicial Affairs of the AMA. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA. 1991;265:1868–71. CrossRef
- U.S. Congress. Patient Self-Determination Act. 1990 Omnibus Budget Reconciliation Act (OBRA): (PL 101-508).
- Miles SH, Bannick-Mohrland S, Lurie N. Advance-treatment planning discussions with nursing home residents: pilot experience with simulated interviews. J Clin Ethics. 1990;1:108–12.
- Miller A, Lo B. How do doctors discuss do-not-resuscitate orders? West J Med. 1985;143:256–8.
- Miller DK, Coe RM, Hyers TM. Achieving consensus on withdrawing or withholding care for critically ill patients. J Gen Intern Med. 1992;7:475–80. CrossRef
- Ventres W, Nichter M, Reed R, Frankel R. Do-not-resuscitate discussions: a qualitative analysis. Fam Pract Res J. 1992;12:157–69.
- Ventres W, Nichter M, Reed R, Frankel R. Limitation of medical care: an ethnographic analysis. J Clin Ethics. 1993;4:134–45.
- Moss AH. Informing patients about cardiopulmonary resuscitation when the risks outweigh the benefits. J Gen Intern Med. 1989;4:349–55. CrossRef
- Appelbaum PS, Lidz CW, Meisel A. Informed consent: legal theory and clinical practice. New York: Oxford University Press, 1987.
- Doukas DJ, McCullough LB. The values history: the evaluation of the patient’s values and advance directives. J Fam Pract. 1991;32:145–53.
- Lo B. Unanswered questions about DNR orders. JAMA. 1991;265:1874–5. CrossRef
- McNeil BJ, Pauler SG, Sox HC, Tversky A. On the elicitation of preferences for alternative therapies. N Engl J Med. 1982;306:1259–62. CrossRef
- Fleiss JL. Measuring nominal scale agreement among many raters. Psychol Bull. 1971;76:378–82. CrossRef
- Smith RC, Hoppe RB. The patient’s story: integrating the patient-and physician-centered approaches to interviewing. Ann Intern Med. 1991;115:470–7.
- Spiro H. What is empathy and can it be taught? Ann Intern Med. 1992;116:843–6.
- Branch WT, Malik TK. Using ‘windows of opportunities’ in brief interviews to understand patients’ concerns. JAMA. 1993;269:1667–8. CrossRef
- Platt FW. Conversation failure: case studies in doctor—patient communication. Tacoma, WA: Life Sciences Press, 1992.
- Quill TE. Recognizing and adjusting to barriers in doctor—patient communication. Ann Intern Med. 1989;111:51–7.
- Kong A, Barnett GO, Mosteller F, Youtz C. How medical professionals evaluate expressions of probability. N Engl J Med. 1986;315:740–4. CrossRef
- Nakao MA, Axelrod S. Numbers are better than words: verbal specifications of frequency have no place in medicine. Am J Med. 1983;74:1061–5. CrossRef
- Bedell SE, Selbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med. 1983;309:579–86. CrossRef
- Taffet GE, Teasdale TA, Luchi RJ. In-hospital cardiopulmonary resuscitation. JAMA. 1988;260:2069–72. CrossRef
- Raviglione MC, Battan R, Taranta A. Cardiopulmonary resuscitation in patients with the acquired immunodeficiency syndrome: a prospective study. Arch Intern Med. 1988;148:2602–5. CrossRef
- Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med. 1994;330:545–9. CrossRef
- Schonwetter RS, Walker RM, Kramer DR, Robinson BE. Resuscitation decision making in the elderly: the value of outcome data. J Gen Intern Med. 1993;8:295–300.
- Danis M, Gerrity MS, Southerland LI, Patrick DL. A comparison of patient, family, and physician assessments of the value of medical intensive care. Crit Care Med. 1988;16:594–600. CrossRef
- Uhlmann RF, Pearlman RA. Perceived quality of life and preferences for life-sustaining treatment in older adults. Arch Intern Med. 1991;151:495–7. CrossRef
- Lipkin M Jr. The medical interview and related skills. In: Branch WT (ed). Office Practice of Medicine. Philadelphia: W. B. Saunders, 1987;1287–306.
- Ende J, Kazis L, Ash A, Moskowitz MA. Measuring patients’ desire for autonomy: decision making and information-seeking preferences among medical patients. J Gen Intern Med. 1989;4:23–30. CrossRef
- Strull WM, Lo B, Charles G. Do patients want to participate in decision making? JAMA. 1984;252:2990–4. CrossRef
- Lipkin M Jr, Quill TE, Napodano RJ. The medical interview: a core curriculum for residencies in internal medicine. Ann Intern Med. 1984;100:277–84.
- How do medical residents discuss resuscitation with patients?
Journal of General Internal Medicine
Volume 10, Issue 8 , pp 436-442
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- advance directives
- communication barriers
- ethics, medical
- informed consent
- physician-patient relations
- resuscitation orders
- Industry Sectors
- Author Affiliations
- 1. the Robert Wood Johnson Clinical Scholars Program, University of California, San Francisco
- 4. the Center for AIDS Prevention Studies, University of California, San Francisco
- 5. the Department of Epidemiology and Biostatistics, University of California, San Francisco
- 6. the Program in Medical Ethics, University of California, San Francisco
- 7. the Division of General Internal Medicine, University of Califfornia, San Francisco