Do-not-resuscitate Order: The Experiences of Iranian Cardiopulmonary Resuscitation Team Members

INTRODUCTION

The cardiopulmonary resuscitation (CPR) as a therapeutic intervention is performed for patients with cardiac and/or respiratory arrest. The success of this intervention is generally measured through the improvement of the patients' survival rate to hospital discharge.[1] The evidence suggests the low success rate of CPR[12] though physicians, patients, and the public overestimate the patients' survival rate after this procedure.[3] The futility of therapeutic interventions and making decisions about conducting CPR is a medical, ethical,[4] and legal challenge,[5] especially in the end-of-life care.[6] Due to the relatively low rate of successful CPR, the costs of ineffective treatment,[7] and high probability of the occurrence of various complications, the American Medical Association for the first time in 1974 formally proposed the do-not-resuscitate (DNR) order in patients' treatment process. Furthermore, in 1976, the first hospital policies with regard to the DNR order were published.[8] Since then, there have always been arguments on the legal and ethical challenges of the DNR order.[5] DNR, do not attempt resuscitation, and allow natural death are the same commands with an equal meaning, which are used by health-care professionals when patients should not be resuscitated in case of cardiopulmonary arrest.[2] According to the American Heart Association, the DNR order should be given by credentialed medical doctor or alternative authorities who are authorized by local laws. It should be prescribed after consultation and obtaining informed consent of the patient, family, or his/her guardian[9] when the patient's prognosis is very poor.[8] Some studies have shown that old age, female gender, white race, decreased cognitive ability, and the diagnosis of disease particularly cancer are associated with the prescription of the DNR order.[10] The attitudes of health-care staff including nurses and physicians toward those patients who are spending the final days of their life have always been a major challenge influencing the decision for performing CPR.[6] This challenge has been perceived in different ways in different countries[11] because it is influenced by a wide range of cultural, religious, ethnical, and geographical factors.[12] In this regard, studies conducted in western countries indicted the positive attitudes of health-care professionals toward the DNR order. In many treatment centers in western countries, concrete policies have been developed with regard to the DNR order.[613] In a few studies conducted in Muslim countries have shown the presence of a negative attitude toward the DNR order.[111415] However, conflicting perspectives about the DNR order in these countries have also been reported.[1617] The limited number of studies and contradictory results about the DNR order in Islamic countries,[111417] recommendations for further studies,[15] the prevalence of the nonstandard, informal and verbal DNR order in many Islamic countries,[18] and a lack of knowledge on the experiences of health-care providers on the DNR order in these countries motivated the researchers to conduct a study. The CPR team members are in the best position to describe factors influencing CPR and how decisions are made for the DNR order. In this respect, their experiences and valuable comments about the DNR order can help qualitative researchers with in-depth understandings of this phenomenon. This study aimed to understand the experiences of CPR team members about the DNR order.

METHODS

RESULTS

The participants' experiences showed that the informal and verbal DNR order existed in their workplace, which made the participants to encounter legal, ethical, and operational challenges. Furthermore, some factors affected the DNR order. The data analysis led to the development of three categories and six subcategories as follow: “The dilemma between revival and suffering” with the subcategories of “revival likelihood” and “death as a cause for comfort;” “conflicting situation” with the subcategories of “latent decision” and “ambivalent order;” and “low-quality CPR” with the subcategories of “team member demotivation” and “disrupting CPR performance.”

DISCUSSION

The exploration of the experiences of the CPR team members showed that factors such as the chances of successful CPR and problems for the patient and family after recovery affected the DNR order. This order has no legal status in the Iranian health-care system. Furthermore, it has created conflicting situation with legal, ethical, and operational challenges for health-care professionals and reduced their motivation and the quality of CPR procedure. To the best of our knowledge, this was the first study conducted in Islamic countries on the experiences of CPR team members with regard to the DNR order.

A lack of hope to the patient's recovery after CPR was the main reason for the DNR order in this study. Other studies also stated that futile therapeutic interventions[422] and the likelihood of CPR failure were some factors affecting decision-making on the DNR order.[1123] In other studies, poor medical conditions and prognosis were mentioned as the underlying factors of the DNR order.[18] In many European countries, when doctors do not believe in the success of CPR or are informed of the CPR's risks, they do not recommend this procedure.[24] Not to be compelled to perform CPR in cases where the risk is more important than the benefit was in line with the subcategory of “death as a cause for comfort” in this study. The high probability of complications as a result of CPR and treatment costs was mentioned in the international literature as causes for the documentation of the DNR order in patients' health file.[811] The future quality of life of patients should be considered the most important factor for the CPR order.[25] CPR health-care team members in this study predicted the consequences and possible problems after CPR and therefore believed that death could be a means of comfort for the patient and his/her family.

We found that the informal and illegal identity of the DNR in the Iranian health-care system made that our participant's encountered ethical and legal challenges and became skeptical about the implementation of this order. Okazi et al. also described the widespread, informal, verbal, and without rules of the DNR order in hospitals in Iran.[18] Other studies also showed that nurses generally had no positive attitude toward the DNR order and believed that the DNR order could lead to legal problems.[15] Furthermore, a fear of legal prosecution had a major role in shaping health-care providers role in decision making for the DNR order.[25] In another study, only 5% of medical students considered the DNR order legally problematic.[26] The probable reason for such a difference could be the different participants of these studies. In this study, participants were physicians and nurses, but in the study of Ghajarzadeh et al., all participants were medical students. Since students have no direct responsibility for patient care, they do not experience any legal challenge. Furthermore, we studied the experiences of the participants through holding interviews, but in the study by Ghajarzadeh et al., the attitudes of medical students were investigated using a questionnaire.[26]

In line with our findings, physicians face ethical dilemma when deciding for the DNR order[27] and nurses when are expected to perform this order.[15] The participants in the study by Kelly also considered the slow code an unconscionable act. Slow code means not making sufficient efforts for the patient recovery,[28] which is consistent with the subcategory of “ambivalent order” in this study. Hesitancy in performing the DNR order and performing tokenistic CPR was another challenge of the participants in this study. The results of other studies showed the presence of difficulties and challenges in the implementation of the DNR order[2930] and increased conflict and ambivalence as the result of this order.[31] Performing tokenistic CPR or the so-called slow CPR for incurable and terminally ill patients was expressed in other studies,[32] which was consistent with the results of this study.

The results of this study also revealed that the DNR order led to reduced willingness and motivation of the CPR team members and therefore affected their performance during CPR. Since the DNR order indicted a lack of chance for the patient recovery, according to the Vroom's expectancy theory, it may lead to losing the motivation of CPR team members. According to this theory, when a person feels that his/her efforts do not lead to expected results, his/her motivation is reduced.[33] Japanese physicians have also found that the DNR order can influence performing the CPR procedure.[34]

CONCLUSION

The DNR order is informal and exists as a verbal order in the Iranian health-care system. Its illegal identity may create many challenges for those who implement it. Therefore, there is a need to the development of a contextual guideline based on the cultural and religious characteristics of Islamic countries. Such a guideline helps with the clarification of the process of the DNR order, which is required for respecting the rights of patients and their family members and providing legal support to health-care professionals during CPR. The findings of this study can be used for the development of such a guideline in the Islamic health-care system.