Residents’ Practices and Perceptions About Do Not Resuscitate Orders and Pronouncing Death: An Opportunity for Clinical Training

Abstract

Background: Although ‘‘Do not resuscitate’’ (DNR) orders are among the most commonly discussed patient preference treatment measures, few studies have assessed internal medicine residents’ views on this complex topic. Our objective was to assess resident practices in establishing code status. We also examined resident training and experiences in pronouncing death. Methods: An 18-question survey addressing DNR discussions and pronouncing death was emailed to internal medicine residents in the state of Illinois. Each question had multiple-choice options. Results: A total of 175 residents completed the questionnaire (22% response rate). Seventy-eight percent of the residents had discussed DNR status with patients or their families at least 9 times. However, only one third of the residents felt very comfortable in such discussions. Only 26% of the residents had been observed by a faculty member during a code status discussion and fewer (16%) while pronouncing death. Do not resuscitate discussions rarely occurred in an outpatient clinic (27%). Most residents (90%) thought they would benefit from formal training in DNR discussion. Conclusion: Although most residents discuss DNR status with patients and families, only a quarter are observed in such discussions by attending physicians and only a third feel comfortable with this aspect of clinical care. Developing a structured residency program curriculum to address resident skills in end-of-life care would benefit residency training.

Keywords

residents do not resuscitate pronouncing death

References

Peberdy MA , Kaye W. , Ornato JP , et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation . Resuscitation. 2003;58(3):297-308.

Covinsky KE , Fuller JD , Yaffe K. , et al. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc. 2000; 48(5 suppl):S187-S193.

Morrison RS , Morrison EW , Glickman DF Physician reluctance to discuss advance directives. An empiric investigation of potential barriers. Arch Intern Med. 1994 ;154(20):2311-2318.

Burns JP , Edwards J. , Johnson J. , Cassem NH , Truog RD Do-not-resuscitate order after 25 years. Crit Care Med. 2003;31(5): 1543-1550.

Sulmasy DP , Sood JR , Ury WA Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. J Med Ethics. 2008 ;34(2):96-101.

Tulsky JA , Chesney MA , Lo B. How do medical residents discuss resuscitation with patients? J Gen Intern Med. 1995; 10(8):436-442.

Eliasson AH , Parker JM , Shorr AF , et al. Impediments to writing do-not-resuscitate orders. Arch Intern Med. 1999;159(18):2213-2218.

Tulsky JA , Chesney MA , Lo B. See one, do one, teach one? House staff experience discussing do-not-resuscitate orders. Arch Intern Med. 1996;156(12):1285-1289.

Quill TE Perspectives on care at the close of life. Initiating end-of-life discussions with seriously ill patients: addressing the ‘‘elephant in the room’’. JAMA. 2000;284(19):2502-2507.

10.

Johnston SC , Pfeifer MP , McNutt R. The discussion about advance directives. Patient and physician opinions regarding when and how it should be conducted. End of Life Study Group. Arch Intern Med. 1995;155(10):1025-1030.

11.

Weissman DE , Mullan PB , Ambuel B. , von Gunten C. End-of-life curriculum reform: outcomes and impact in a follow-up study of internal medicine residency programs. J Palliat Med. 2002;5(4): 497-506.

12.

Kuhl DR , Calam B. , Westwood M. A workshop for first-year residents on discussing ‘‘code status’’ in hospitals. Acad Med. 2001;76(5):560-561.

13.

Stevens A. , Hernandez J. , Johnsen K. , et al. The use of virtual patients to teach medical students history taking and communication skills. Am J Surg. 2006;191(6):806-811.

14.

Deep KS , Green SF , Griffith CH , Wilson JF Medical residents’ perspectives on discussions of advanced directives: can prior experience affect how they approach patients? J Palliat Med. 2007;10(3):712-720.

15.

Bailey FA , Williams BR Preparation of residents for death pronouncement: a sensitive and supportive method. Palliat Support Care. 2005;3(2):107-114.

16.

Marchand L. , Kushner K. Death pronouncements: using the teachable moment in end-of-life care residency training. J Palliat Med . 2004;7(1):80-84.