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Physicians base DNR decisions primarily on institutional policies

Physicians working in hospitals with policies that reflect best-interest regarding do-not-resuscitate orders are comfortable suggesting against resuscitation, compared with physicians in hospitals that emphasized autonomy, according to data.

“Institutional cultures and policies might influence how physician trainees develop their professional attitudes toward autonomy and their willingness to make recommendations regarding the decision to implement a [do-not-resuscitate] order. A singular focus on autonomy might inadvertently undermine patient care by depriving patients and surrogates of the professional guidance needed to make critical end of life decisions,” Elizabeth Dzeng, MD, MPH, MPhil, of the division of general internal medicine at Johns Hopkins School of Medicine and colleagues wrote.

Researchers performed semistructured in-depth qualitative interviews on 58 internal medicine physicians, over a 9-month period. Participants were recruited from four different academic medical centers located in urban areas, three in the U.S. and one in the U.K. Hospitals were chosen based on expected differences in culture and policies concerning prioritization of autonomy versus best interest in do-not-resuscitate orders.

The researchers made note that hospitals A and B, both located in the U.S., had policies and cultures that emphasized patient autonomy, while hospitals C and D had policies and cultures that emphasized best-interest decision making.

Overall results demonstrated that physician trainee’s philosophies regarding do-not-resuscitate (DNR) orders reflected their hospital’s polices and culture. Trainees who worked in autonomy-focused institutions seemed to recommend resuscitation, regardless of whether or not it was likely to be successful. However, physician trainees in centers that had a best-interest approach reported being okay with recommending DNR to patients with a low-survival likelihood.

Experienced physicians reported that their DNR decisions and recommendations were not solely based on their centers’ policies and cultures. They also felt comfortable suggesting against resuscitation when they believed it would be futile, regardless of their institutions policies.

“It is ironic that the very policies that seek to empower patients might inadvertently deprive them of their autonomy through an overemphasis on a reductionist checklist approach to autonomy. Perhaps policies more oriented toward best-interest decision making might allow physicians the leeway to shift their focus from a discourse of choice to one of care and compassion,” Dzeng and colleagues wrote. – by Casey Hower

Disclosure: The researchers report no relevant financial disclosures.