Most elderly patients die with an order in place that they not be given cardiopulmonary resuscitation . Surveys have shown that many elderly in different parts of the world want to be resuscitated, but may lack knowledge about the specifics of cardiopulmonary resuscitation . Data from countries other than the US is limited, but differences in physician and patient opinions by nationality regarding CPR do exist. Physicians’ own preferences for CPR may predominate in the DNR decision making process for their (...) patients, and many physicians may not want the participation of the elderly or believe that it is necessary. More complete and earlier discussions of a wider range of options of care for patients at the end of life have been advocated. The process ought to include education for patients about the process and efficacy of CPR, and for physicians on how to consider the values and levels of knowledge of their patients, whose preferences may differ from their own. (shrink)

Objectives: This study investigated Finnish physicians’ experiences of decisions concerning living wills and do not resuscitate orders and also their views on the role of patients and family members in these decisions.Design: A questionnaire was sent to 800 physicians representing the following specialties: general practice ; internal medicine ; neurology , and oncology .Results: The response rate was 56%. Most of the respondents had a positive attitude toward , and respect for living wills, and 72% reported situations in which such (...) a will would have been helpful, although experience with their use was limited. The physicians reported both benefits and problems with living wills. Thirteen per cent had completed a living will of their own. Half did not consider living wills to be reliable if they were several years old. Do not resuscitate orders were interpreted in two ways: resuscitation forbidden or only palliative care required . The respondents also documented DNR orders differently. Seventy two per cent discussed DNR decisions always or often with patients able to communicate, and even 76% discussed DNR orders with the family members of patients unable to communicate. Most respondents were able to approach a dying patient without difficulty. They also felt that education in general was needed.Conclusions: In general Finnish physicians accept living wills, but find they are accompanied by several problems. Many problems could be avoided if physicians and patients conducted progressive discussions about living wills. The differing interpretations of DNR orders are a matter of concern in that they may affect patient treatment. The promotion of patient autonomy with respect to treatment seems rather good, but the limitations of the study need to be kept in mind. (shrink)

Objectives: This study investigated Finnish physicians’ experiences of decisions concerning living wills and do not resuscitate orders and also their views on the role of patients and family members in these decisions.Design: A questionnaire was sent to 800 physicians representing the following specialties: general practice ; internal medicine ; neurology , and oncology .Results: The response rate was 56%. Most of the respondents had a positive attitude toward , and respect for living wills, and 72% reported situations in which such (...) a will would have been helpful, although experience with their use was limited. The physicians reported both benefits and problems with living wills. Thirteen per cent had completed a living will of their own. Half did not consider living wills to be reliable if they were several years old. Do not resuscitate orders were interpreted in two ways: resuscitation forbidden or only palliative care required . The respondents also documented DNR orders differently. Seventy two per cent discussed DNR decisions always or often with patients able to communicate, and even 76% discussed DNR orders with the family members of patients unable to communicate. Most respondents were able to approach a dying patient without difficulty. They also felt that education in general was needed.Conclusions: In general Finnish physicians accept living wills, but find they are accompanied by several problems. Many problems could be avoided if physicians and patients conducted progressive discussions about living wills. The differing interpretations of DNR orders are a matter of concern in that they may affect patient treatment. The promotion of patient autonomy with respect to treatment seems rather good, but the limitations of the study need to be kept in mind. (shrink)

Objectives—To study the value of taking an ethics history as a means of assessing patients' preferences for decision making and for their relatives' involvement.Design—Questionnaire administered by six junior doctors to 56 mentally competent patients, admitted into general and geriatric medical beds.Setting—A large district general hospital in the United Kingdom.Main measures—To establish whether patients were adequately informed about their illness and whether they minded the information being communicated to their relatives. To establish their preference regarding truthful disclosure and participation in decision (...) making with risk attached. To establish whether they wished to be involved in CPR decision making, and if not, who should make the decision. To establish whether they knew of living wills and whether they had any advance directives.Results—Twenty-four were inadequately informed of their illness.Forty-six said they would want to know were something serious to be found. Twenty-eight wanted to make their own decision if requiring risky treatment and 11 wanted family members involved. Thirty-one wanted to make a cardiopulmonary resuscitation decision and five of these decisions differed from those made by the doctors. Twenty-five preferred the doctors to decide. Eleven of the patients had heard of living wills but only one had executed such a will. Seven of the patients wished to provide advance directives. Three did not find the history taking helpful but none were discomforted.Conclusion—Taking an ethics history is a simple means of obtaining useful information about patients' preferences. (shrink)

ABSTRACT In keeping with the pre‐eminent status accorded autonomy within Australia, Europe, and the United States, medical practice requires that patients authorize do‐not‐resuscitate (DNR) orders, intended to countermand the default practice in hospitals of instituting cardiopulmonary‐resuscitation (CPR) on all patients experiencing cardio‐pulmonary arrest. As patients typically do not make these decisions proactively, however, family members are often asked to act as surrogate decision‐makers and decide on the patient's behalf. Although the appropriateness of patients or their families having to decide about (...) the provision of CPR has been challenged, there has been little examination of how patients and their families talk about and negotiate such decisions, particularly in the context of the patient's imminent death. In this article, part of a larger study analysing interviews with 28 patients (13 female) with cancer within weeks of their death, and 20 others (predominantly family) attending, we argue that a common assumption underpinning participants' talk about the DNR decision (i.e. forgoing CPR) is that it requires a choice between life and death. Using illustrative examples, we demonstrate that in making decisions about CPR, patients and their families are implicitly required to make moral judgements about the value of the patient's life, including their relationships with significant others. We identify some implications of these empirical observations for the development of ethically appropriate policies and practices regarding patient autonomy and surrogacy at the end of life. (shrink)