Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice.

BACKGROUND: The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR. METHODS: The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019. RESULTS: A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001). CONCLUSION: During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

Factors Influencing Family Surrogates' Intention with Regard to Do-Not-Resuscitate Directive for Patients with Dementia.

Objective: To investigate the prevalence of family surrogates' do-not-resuscitate (DNR) intention for patients with dementia (PwD), and factors influencing family surrogates' decisions. Methods: This is a descriptive and cross-sectional study. Patients with dementia and their family surrogates from Dementia Outpatient Clinic of a teaching hospital in southern Taiwan were included. Data were collected using chart review and questionnaire survey. Influential factors were analyzed using multiple logistic regression. Results: One hundred and forty of the 223 participants (62.8%) have intention to sign DNR consents for their dementia relatives. Factors influencing the intention were: (1) Comorbid with musculoskeletal diseases or diabetes (p < .05); (2) psychological symptoms of repetitive wording and behavior (p < .05); (3) spouse (p < .05) and lineal relatives (p < .01); (4) previous discussion between families and patient about DNR directive (p = .001); (5) believers of Taiwan folk belief (Buddhism or Taoism) (p < .05). Conclusions: Advanced dementia patients cannot express intention about their end-of-life care and depend on family surrogates to decide for them. Our study showed that spouse and direct relatives, comorbidities of musculoskeletal disease or diabetes, psychological symptoms of repetitive wording and behavior, previous discussion about patients' intention, and believers of Taiwan folk belief are all positive influencing factors for surrogates to consent DNR directive for patients. Our findings are important in promoting DNR directive for PwD. Clinical implications: Our results may help to promote DNR decisions for dementia patients, especially in Chinese populations.

Medical futility: a paradigm as old as Hippocrates.

Medical futility is a concept commonly used to describe medical therapy that has no known or anticipated immediate or long-term benefit for a patient. The concept of futility has existed since the time of Hippocrates and has become the predominant dilemma for many end-of-life situations. Today, clinicians grapple with ethical conflicts and concepts in their daily practice. Many healthcare providers use the concept of medical futility when they are talking with patients and families who are in a quandary about their loved one's care. This article provides an overview of medical futility.

DNR versus DNT: clinical implications of a conceptual ambiguity: a case analysis.

Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions, such as resuscitation and intubation. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that may be addressed by psychiatrists who practice psychosomatic medicine.

Virtue ethics: an approach to moral dilemmas in nursing.

Nurses are increasingly confronted with situations of moral difficulty, such as not to feed terminally ill patients, whistle blowing, or participation in termination of pregnancy. Most of these moral dilemmas are often analyzed using the principle-based approach which applies the four moral principles of justice, autonomy, beneficence, and non-malificence. In some instances, consequentialism is considered, but these frameworks have their limitations. Their limitations has to do with a consideration for the interpersonal nature of clinical nursing practice on the one hand, and is not always clear on how to judge which consequences are best on the other hand. When principles are in conflict it is not always easy to decide which principle should dominate. Furthermore, these frameworks do not take into account the importance of the interpersonal and emotional element of human experience. On the contrary, decision-making about moral issues in healthcare demands that nurses exercise rational control over emotions. This clearly focuses the attention on the nurse as moral agent and in particular their character. In this article I argue that virtue ethics as an approach, which focus of the character of a person, might provide a more holistic analysis of moral dilemmas in nursing and might facilitate more flexible and creative solutions when combined with other theories of moral decision-making. Advancing this argument, firstly, I provide the central features of virtue ethics. Secondly I describe a story in which a moral dilemma is evident. Lastly I apply virtue ethics as an approach to this moral dilemma and in particular focusing on the virtues inherent in the nurse as moral agent in the story.

Pediatric resuscitation: questioning DNAR legitimacy and offering an alternative decision-making model.

The views expressed in this paper are those of the author and do not necessarily represent those of the American Medical Association.

Do-not-resuscitate orders and medical futility.

This report addresses the difficult situation in which a patient or surrogate decision maker wishes cardiopulmonary resuscitation to be attempted even though the physician believes that resuscitation efforts would be futile. It also reviews current controversies surrounding the subject of do-not-resuscitate (DNR) orders and medical futility, discusses the complex medical, legal, and ethical considerations involved, and then offers recommendations as a guide to clinicians and ethics committees in resolving these difficult issues. Conflicts over DNR orders and medical futility should not be resolved through a policy that attempts to define futility in the abstract, but rather through a predefined and fair process that addresses specific cases and includes multiple safeguards. As it examines these issues, the report focuses on the Veterans Health Administration (VHA). Current national VHA policy constrains physicians from entering a DNR order over the objection of a patient or surrogate even if the physician believes cardiopulmonary resuscitation to be futile. The VHA National Ethics Committee recommends that VHA policy be changed to reflect the opinions expressed in this report. The National Ethics Committee, which is composed of VHA clinicians and leaders, as well as veterans advocates, creates reports that analyze ethical issues affecting the health and care of veterans treated in the VHA, the largest integrated health care system in the United States. This report does not change or modify VHA policy.