Beliefs and attitudes of nurses and physicians about do not resuscitate orders and who should speak to patients and families about them.

OBJECTIVE: Both physicians and nurses play important roles in discussing do not resuscitate (DNR) orders with patients and surrogates. However, the beliefs and attitudes of health professionals about the role nurses should play in this process have received little systematic study. DESIGN AND SETTING: An anonymous survey was conducted of 217 attending internists, 132 medical house officers, and 219 staff nurses working on the medical floors and units at two teaching hospitals about their beliefs, attitudes, and confidence regarding DNR discussions. RESULTS: Attendings and house officers were more likely than nurses to believe that nurses should never initiate DNR discussions (p < .001). Nonetheless, 69% of both physician groups agreed that nurses should be allowed to do so. Nurses were the most likely of the three groups to consider DNR discussions rewarding clinical experiences (p < .001). In a multivariate ordinal regression model controlling for sex, attitudes about DNR discussions, and confidence in discussing consent for medical procedures, nurses were less confident than attendings (p = .04) but more confident than house officers in their ability to discuss DNR orders (p = .02). CONCLUSIONS: Staff nurses were more likely than their physician colleagues to believe they should be allowed to initiate DNR discussions, were more confident in their ability to discuss DNR than house officers, and had more positive attitudes. These results suggest further exploration of the role nurses should play in the DNR process.

The surrogate's experience in authorizing a do not resuscitate order.

OBJECTIVE: Little is known about the subjective experience of surrogates who authorize do not resuscitate (DNR) orders. This experience seems especially acute in settings such as New York State, where patients and surrogates generally give written consent for DNR orders. The goal of this study is to investigate the subjective and emotional experience of surrogates who authorize DNR orders in this setting. METHODS: A qualitative, phenomenological research design was used. Surrogates of patients on the medical service were approached no earlier than 1 day and no later than 7 days after authorizing a DNR order. The interview guide was open-ended and included general prompts. Interviews were taped and transcribed. Researchers then coded the transcripts and examined the data for clusters of themes. They then met to discuss and recode disagreements. RESULTS: Saturation was met after 10 subjects were interviewed. The following major surrogate themes were found: (1) Signing a DNR order is a process, not an isolated act. (2) The presence or absence of good quality communication and psychological support from health care personnel are among the most important factors in this process. (3) The process of signing a DNR order can raise many negative emotions including guilt, ambivalence, and conflict. (4) Prior discussions, documents such as living wills, and consensus among family members make it easier to determine the patient's wishes and carry them out by signing the DNR. (5) The surrogates believed that signing a DNR order is a prerequisite to obtaining adequate opioid analgesia. SIGNIFICANCE OF RESULTS: The experience of authorizing a DNR order is a complex and emotional decision-making process. Evidence of the patient's prior wishes and support from health care personnel make the process easier. It is disconcerting that surrogates viewed DNR orders as a prerequisite to obtaining relief for a patient's pain or suffering.

A prospective trial of a new policy eliminating signed consent for do not resuscitate orders.

BACKGROUND: Some institutions require patients and families to give signed consent for Do Not Resuscitate (DNR) orders, especially in New York State. As this may be a barrier to discussions about DNR orders,we changed a signed consent policy to a witnessed verbal consent policy,simplified and modified the DNR order forms, and educated the staff at 1 hospital, comparing the effects with an affiliated hospital where the policy was not changed. DESIGN: Prospective natural experiment with intervention and comparison sites. SUBJECTS AND MEASUREMENTS: Pre- and postintervention, we surveyed house officers' confidence and attitudes, reviewed charts to assess the number of concurrent care concerns (CCCs) addressed per DNR order (e.g., limits on intubation or blood products or need for hospice),and at the intervention hospital, measured the stress levels of surrogates consenting for DNR orders using the Horowitz Impact of Event Scale. We also surveyed staff perceptions about the policy following the change. RESULTS: At the intervention hospital, the percentage of house officers reporting low confidence in their ability to obtain consent for DNR orders declined postintervention (24% to 7%, P=.002), while there was no significant change at the comparison hospital (20% vs 15%, P=.45).Among intervention hospital house officers, there were declines in percent reporting difficulty talking to patients and families about DNR orders, but no significant changes at the comparison hospital.At the intervention hospital, the mean number of CCCs/DNR order Increased (1.0 pre to 4.2 post, P<.001). but did not change significantly(1.2 pre to 1.4 post) at the comparison hospital. The mean total stress score for intervention hospital surrogates declined postintervention(23.6 to 17.3, P=.02), indicating lower stress. House officers(98%), attendings (59%), and nurses (79%} thought the new policy was better for families. CONCLUSIONS: The policy change was well received and associated with improved house officer attitudes, more attention to patients'concurrent care concerns, and decreased surrogate stress. The results suggest that DNR orders can be made simpler and clearer, and raise questions about policies requiring signed consent for DNR orders.

Tube feeding in advanced dementia: an exploratory survey of physician knowledge.

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians' lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non-evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education ofprimary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.

The quality of care plans for patients with do-not-resuscitate orders.

BACKGROUND: Care plans for patients with do-not-resuscitate (DNR) orders often fail to define limits other than cardiopulmonary resuscitation and fail to address other patient care needs. We studied the explicitness and comprehensiveness of care plans for patients with DNR orders and what factors were associated with this aspect of the quality of their care. METHODS: A cross-sectional study was conducted at Georgetown University Medical Center (GUMC), Washington, DC, and St Vincent Catholic Medical Centers (SVCMC), St Vincent's Hospital-Manhattan, New York, NY. Participants included 189 consecutive medical inpatients with DNR orders. RESULTS: A previously validated medical chart review technique termed concurrent care concerns (CCCs) measured whether 11 possible patient care needs had been addressed within 2 days of the DNR order. Reasons for the DNR order were documented in only 55% of cases, and a consent conversation was documented in only 69%. The mean number of total CCCs per DNR order was 1.55 (1.84 at GUMC and 1.29 at SVCMC; (P =.007). In a multivariate logistic regression analysis of low (or=2) CCCs, patients with malignancy (P =.002), higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (P =.007), and a documented consent conversation (P =.009) and those at Georgetown (P =.005) were more likely to have high attention to CCCs. Patients with dementia were the least likely to have high attention to CCCs. CONCLUSIONS: Documented consent conversations and care plans for patients with DNR orders are less than ideal. Care plans differ in quality by diagnosis, institution, and whether or not a consent conversation is documented. These observations might help to guide interventions that aim to improve the care of patients with DNR orders.

Assessing medical students' training in end-of-life communication: a survey of interns at one urban teaching hospital.

PURPOSE: Although interns are responsible for caring for dying patients, little is known about end-of-life education and training, including communication skills, in U.S. medical schools. This study of three consecutive cohorts of new interns assessed their perceptions of the amount and types of classroom and clinical instructional strategies used during medical school, their self-rated skill and comfort levels in different aspects of end-of-life communication, and the associations between these measures. METHOD: A self-administered questionnaire was given to three consecutive cohorts (1996-1998) of incoming interns (n = 162). Measures were self-reported amount and type of education and clinical experience with four end-of-life communication domains (giving bad news, discussing advance directives, discussing prognosis with the patient, and discussing with the patient's family) and self-perceived comfort and skill levels in relation to different types of end-of-life communication. RESULTS: A total of 157 interns completed the questionnaire. They reported very little classroom teaching, clinical observation, or clinical experience with end-of-life communication during medical school. They lacked comfort and skill in the end-of-life communication domains that were studied. More reported clinical observation and experience with caring for and communicating with dying patients was associated with greater perceived comfort and skill, while classroom teaching was not. CONCLUSIONS: These interns, mostly U.S. medical school graduates (98.7%, n = 155) reported little training and low self-perceived comfort and skill with important elements of end-of-life communication that might contribute to a lack of preparedness to address these issues during their internship. Further research that confirms and explains the underlying reasons for these findings seems warranted.

Palliative care curriculum development: a model for a content and process-based approach.

To ensure its success, a new curriculum has to meet the needs of learners, patients, and the institution. A review of the literature indicates that despite a tremendous need for palliative care services and a lack of appropriate knowledge and attitudes among physicians, few palliative care curricula for medical residents have been developed. Most are developed by national organizations, and as a result can not meet the individual needs of different institutions. This paper outlines the process of developing a palliative care curriculum in the context of available institutional resources that meets the learners' needs. The development of a curriculum can be divided into four phases: needs assessment, curricular design, implementation, and evaluation. Content (curricular content, instructional strategies and available resources for the curriculum and the developmental process) and process (methods through which the curriculum is developed and institutional issues are addressed) issues that are pertinent to the successful completion of each phase are discussed. Two hypothetical institutions are used to illustrate relevant issues. Methods that have been successfully used to develop residency curricula are discussed.

Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?

BACKGROUND: Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices. DESIGN: Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars. MEASUREMENTS: Consecutive pharmacy and billing records of patients who were cared for by medical residents (n = 733) and a comparison group of neurology and rehabilitative medicine patients (n = 273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs). MAIN RESULTS: The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline. CONCLUSIONS: This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents' opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.