the doctors’ perspecive
Elzio Luiz Putzel 1, Klisman Drescher Hilleshein 2, Elcio Luiz Bonamigo 3Abstract
The do-not-resuscitate order is the explicit statement by paients with advanced disease in progression refusing cardiopulmonary resuscitaion. This study aimed to describe the aitude of physicians in relaion to the this order and the need for its regulaion. A quesionnaire was applied to 80 physicians in the medical bureau of the Regional Council of Medicine of Joacaba/SC, Brazil. It was found that 90% of the respondents knew the meaning of do-not-resuscitate, 86.2% agreed to respect it, 91.2% considered it important to be registered in medical records and 92.5% understood as opportune the issuance of a regulaion in this regard. It was concluded that most doctors knew about the do-not-resuscitate order, agreed to respect it, valued its registraion in medical records and wanted its regulaion by the relevant bodies.
Keywords: Terminally ill. Bioethics. Resuscitaion orders. Heart massage. Respiraion, ariicial. Medical fuility.
Resumo
Ordem de não reanimar pacientes em fase terminal sob a perspeciva de médicos
Ordem de não reanimar consiste na manifestação expressa da recusa de reanimação cardiopulmonar por
paciente com doença avançada em progressão. Objeivou-se descrever a aitude dos médicos em relação à ordem de não reanimar e à necessidade de sua normaização. Foi aplicado quesionário a 80 médicos inscritos na delegacia do Conselho Regional de Medicina de Joaçaba/SC, Brasil. Veriicou-se que 90% dos paricipantes conheciam o signiicado dessa ordem, 86,2% concordavam em acatá-la, 91,2% consideravam importante seu registro em prontuário e 92,5% consideravam oportuna a emissão de normaização a respeito. Concluiu-se que a maioria dos médicos inha conhecimento sobre Ordem de Não Reanimar, concordava em respeitá-la, valorizava seu registro em prontuário e desejava a normaização por parte dos órgãos competentes.
Palavras-chave: Doente terminal. Bioéica. Ordens de não ressuscitar. Massagem cardíaca. Respiração ariicial. Fuilidade médica.
Resumen
La orden de no reanimar a los pacientes en fase terminal bajo la perspeciva de los médicos
La orden de no reanimar es la manifestación expresa de rechazo de la reanimación cardiopulmonar por par
-te de pacien-tes portadores de una enfermedad avanzada en progresión. Es-te estudio tuvo como objeivo describir la acitud de los médicos con respecto a esta orden y la necesidad de su regulación. Se aplicó un cuesionario a 80 médicos inscriptos en el distrito del Consejo Regional de Medicina de Joaçaba/SC, Brasil. Se encontró que el 90% de los encuestados conocían el signiicado de esta orden, el 86,2% estaban de acuerdo
en cumplirla, el 91,2% consideraban importante el registro en el historial médico y el 92,5% juzgaban oportu
-na la existencia de u-na regulación al respecto. Se concluyó que la mayoría de los médicos tenía conocimiento de la orden de no reanimar, estaba de acuerdo en respetarla, valoraba su registro en el historial médico y deseaba su regulación por parte de las insituciones competentes.
Palabras clave: Enfermo terminal. Bioéica. Órdenes de resucitación. Masaje cardíaco. Respiración ariicial. Inuilidad médica.
Aprovação CEP-Unoesc 495.442/2013
1. Graduando [email protected] – Universidade do Oeste de Santa Catarina (Unoesc) 2. Graduando klisman.drescherhilleshein@ gmail.com – Unoesc 3. Doutor[email protected] – Unoesc, Joaçaba/SC, Brasil.
Correspondência
Elcio Luiz Bonamigo – Rua Francisco Lindner, 310 CEP 89600-000. Joaçaba/SC, Brasil.
Declaram não haver conlito de interesses.
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Do not resuscitate Order (DNR) consists in the
deliberaion of do not trying cardiopulmonary re
-suscitaion in terminally ill paients, with irreversible
loss of conscience or non-treatable cardiac arrest 1.
DNR has been part of the Code of Ethics of the
American Medical Associaion (AMA) since 1992 2.
In Europe, between 50% and 60% of paients which
had sudden death in hospitals of countries such as
Holland, Switzerland, Denmark and Sweden have
declared individual decision of non resuscitaion 3.
However, the global scenario related to profession
-als’ conduct is not uniform, due to the difereniated
cultural factor and to the lack of consensus and
global guidelines 4.
In the Brazilian scenario, the ethical discussion
has arisen mainly in the past two decades 5 and it
was recently fostered by acions taken by the Fed
-eral Medical Board (CFM) which simulate debates
in respect of terminality. Those iniiaives are evi
-denced mainly by the publicizing of resoluions CFM
1.805/2006 6 and 1.995/2012 7, which approach, re
-specively, terminal paients ’therapeuic limitaion and advance direcives (living will). In public health, the rejecion of treatment is an integrated part of the Leter of the Health Users Rights, issued by the
Health Ministry 8. DNR is presented as a complement
to the living will for paricular situaion in which the
paient opts for the non-resuscitaion in case of car
-diorespiratory arrest.
Speciic ethical standards in force in Brazil on DNR were not found, but the procedure is evident
in the hospitals, as atest the registers in medical re
-cords 9. In that context, the aim of this research was
to learn about the physicians’ perspecive on DNR and the need for ethical regulaion.
Method
It is a descripive and cross-secional study performed by means of a quesionnaire applied to
physicians from Joaçaba’s Regional Council of Med
-icine medical bureau, in the state of Santa Catarina, who agreed to paricipate and signed the free and
clariied consent term. The physicians were person
-ally contacted from September to November 2014
and when they were unavailable to answer, the sur
-vey instrument was delegated to the secretaries,
accompanied by the necessary clariicaions. The in
-dividual quesionnaires comprise 14 muliple choice quesions, of which three of socio-demographic interest (age, being a specialist or not, workplace) and eleven with paricular approach on DNR. The
staisical analysis was realized by means of BioEstat 5.0 and GraphPAdPrism. The staisical tests used were G and Fisher’s Test, with signiicance level of
95% (p < 0.05).
Outcome
Of a universe of 160 physicians registered in the Regional Council of Medicine medical bureau, 105 were invited (66%) and 80 agreed to paricipate in the research (50% of the total registered and 76% of the invited physicians), consituing the sample studied.
The average age was 39.4 years, with standard
deviaion of ± 11.9; however, 25 (31%) did not in
-form the age. In regard to the age ranges of those who informed, 22 (28%) were between 25 and 35
years; 22 (28%) between 36 and 45 years; 6 (9%) be
-tween 46 and 55 years; and 5 (6%) with age above 55 years. Regarding the specialty, 68 physicians
(85%) declared themselves as holders of a ceriica
-ion of specialist and 12 (15%), declared they did not hold a ceriicaion of specialist.
Concerning the place of the professional prac
-ice, quesion in which the paricipants may opt for more than an answer, 49 (61%) informed working in a private clinic, 37 (46%) in hospitals – both public health system and private –, 11 (14%) in a primary care unit (UBS) and 2 (3%) in mobile urgency care service (Samu).
The term “Do Not Resuscitate Order” was
known by 72 paricipants (90%), without signii
-cant diferences between age ranges and between
condiion of being a specialist or not (p < 0.05). It is
emphasized that only 10% did not know about the procedure.
Quesioned about the existence of ethical di
-recives about DNR in Brazil, 59 paricipants (74%)
answered posiively. In relaion to the need of prepa
-raion of guidelines about DNR in Brazil, almost the
totality agreed – 74 (92%) –, and only 6 (8%) dis
-agreed. The fact of being a specialist or not, age and
workplace did not inluence the result (p<0,05).
About the possibility of involvement in law
-suit due to DNR prescripion, 42 (53%) disagreed totally, 16 (20%) disagreed a litle, 14 (18%) agreed totally and 8 (10%) agreed a litle. If the paient had
manifested previously the desire of not being re
-suscitated, 69 paricipants (86%) would prescribe or execute their determinaion and 14% would not,
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without signiicant staisical variaion due to age
ranges and to being a specialist or not (p < 0.05).
The previous personal paricipaion in as
-sistance to cardiorespiratory arrest paients was
conirmed by 71 paricipants (88.7%) and disap
-proved by 9 (11.3%). When asked whether paient’s
age would inluence decision making in resuscitat
-ing or not, 38 (48%) answered airmaively and 42 (52%) negaively, and it was veriied that the youngest physicians would take into consideraion the age of the paient at the ime of decision taking
(p < 0.05).
The register of DNR in the paient’s medical
records was considered very important by 51 par
-icipants (63%), important for 22 (28%), of litle importance for 2 (3%), without importance for 4 (5%), and 1 (1%) did not answer.
Oping for DNR was considered joint prerog
-aive of physicians and rel-aives by 45 paricipants (55%); of physicians, nurses and relaives by 22 (28%); only of the physician by 8 (10%); only of the relaives by 3 (4%); and 2 (3%) did not answer. The opions “physician and nurse” or “only nurses” were not chosen.
The physicians were also quesioned about
non-resuscitaion of a relaive in a terminal situa
-ion, in case there were no available therapeuic
condiions for the cure and this was his will. 74 par
-icipants declared to be favorable (93%), and 6 (7%) to be unfavorable.
The paricipants were quesioned if they, in case they were in a terminal stage of an irreversible
disease, would desire that their previous mani
-festaion be taken into consideraion in case of
cardiorespiratory arrest. From the total of the inter
-viewees, 75 (94%) answered airmaively and 5 (6%) negaively. Of the physicians who would desire to have their DNR respected, 67 (89%) would respect the DNR of their paients and 8 (11%) would not. Of the 5 physicians who would not desire their DNR to be respected, 2 (40%) would respect the DNR of
their paients and 3 (60%) would not (p < 0.05).
Discussion
The term “Do Not Resuscitate Order” was known by 90% of the surveyed physicians. The fact
some of them not knowing about it seemed excep
-ional, considering it is a procedure to be always considered in case of paient’s cardiorespiratory arrest when the procedure is conigured as fuile.
Internaional studies which have invesigated phy
-sicians’ knowledge about DNR are rare. However, a study performed in the United States presented an even greater unfamiliarity, considering that among
a hundred resident physicians of a hospital, a third
part had never heard about DNR 10.
The minority of the surveyed physicians (26%) answered correctly that there is no regulaion
on DNR in Brazil. Our country is sill in the legisla
-ive shade regarding some aspects of terminality. However, advance in the ethical scope is already noiceable, mainly with to issue of Resoluion CFM
1.805/2006 6 and of aricle 41 of the Código de Éica
Médica(Medical Ethical Code) 11 which admit ther
-apeuic limitaion in cases correctly indicated, ater obtaining the consent.
As observed in the results, few physicians sill
had not paricipated in cardiorespiratory resuscita
-ion maneuvers. A study performed in the inland of the State of São Paulo veriied that only 65% of the
physicians had experience with terminal paients 12.
However, the opportunity to paricipate of paients’ resuscitaion may occur at hospital emergencies in general, jusifying that most of them had had that experience at some point.
The majority of the surveyed physicians
(85%) answered that they would execute or pre
-scribe DNR authorized by the paient. A study in a
hospital in Israel has shown that 67% of the phy
-sicians would accept the DNR of the paients, but among the relaives, only 33% would be favorable, evidencing the diference of concepion between
physicians and the family 13. Another study in units
for burned paients, with American and European intensivist, has detected an acceptance rate a litle
lower among professionals: 54% 14. In the assistance
to paients who opted for the DNR and that were previously subjected to extra-hospital resuscitaion maneuvers, there were procedures limitaion such as blood transfusion, cardiac catheterizaion and
by-pass implantaion, evidencing the respect to the
direcives, when existent 15.
This study veriied that the physicians were
divided in relaion to the paient’s age factor for de
-cision-making regarding DNR, which was considered
relevant for the younger physicians. An interna
-ional study has shown that, although the increase of age makes the cardiopulmonary resuscitaion
results worse, this factor did not inluence the assis
-tant physician in the decision 16. On the other hand,
when analyzing the electronic system records of two
hospitals in Nashville, it was veriied that older pa
-ients, and with more severe disease presented in
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greater numbers of records about procedures that they desired to receive or not in the terminal phase
of life making the procedure easier 17. However,
when some requests made to the ethics commitee of Massachusets General Hospital, in Boston, were
reviewed, it was veriied that restricion of resusci
-taion maneuvers were not more frequent in older
paients 18.
As the situaion implies in a decision depen
-dent on several factors, in which age evi-dently
reduces the rate of success of cardiorespiratory
resuscitaion 19, some professionals take it into
con-sideraion. Considering the fact that the youngest professionals interviewed in this research consider
the relevance of the age of the paients for a deci
-sion, whose cause was not quesioned, allows for relecions. On the one hand, it is possible that older
physicians, due to their educaion or to their prox
-imity to the end of life, tend to accept the execuion of procedures to extend life. On the other hand, it may be presumed younger physicians due to ethical direcives and scieniic informaion received more recently, adopt a less recepive posiion.
In respect to the importance of the register
-ing of the DNR in medical records, the majority has
considered “very important” or “important”, re
-gardless of age ranges or workplace (p > 0.05). In
that aspect, recent guidance has arisen from Res
-oluion CFM 1.995/2012 7, which has considered
valid the register, in the medical records, of the wills of the paient concerning the cares he wants to receive or not when unable to communicate. The lack of DNR regulaion in Brazil may cause, among physicians, concern both in discussing the issue with the paients and in registering such procedure in the medical records.
In this sense, the research ideniied the exis
-tence of divergence between the register in medical records and the pracice of not resuscitaing a child
paient in a terminal stage 17, as there was no register
of that direcive, 40 in a total of 176 cardiorespiratory arrests did not receive cardiopulmonary resuscitaion. The physicians, paricipants in this survey, regarded important the register of non-resuscitaion in the medical records, being one of the possible steps to demysify the issue. However, it is rare in the medical records the register of the communicaion to relaives
about terminality of life 20, and such aspect needs to
be improved by means of paricular direcives and di
-rected medical educaion.
In those places where DNR has already been established, the acceptance and the engagement of the paients are more frequent. In Indiana University
Hospital, in the United States, it was conirmed that 64.2% of the deaths in surgical hospitalizaion and
77.3% of the deaths in clinical hospitalizaion pre
-sented DNR in medical records 21. Another survey
also in the United States veriied that the fact of
having opted for DNR gave the oncological non-re
-sponsive paients a beter quality of life in the last
week of existence 22. DNR is a tool of fundamental
importance for care in terminality, but should
re-ceive a delicate approach and in the due moment
during the paient’s hospitalizaion, prevening un
-necessary stress in situaions at low risk 17.
When asked about who should opt for do not resuscitate order, most paricipants indicated the physicians together with relaives. In a previous study on preparaion of the living will, there was a preference, both among paients or among their companions, for the paricipaion of the physician
together with the family 23. That agreement is re
-peated now, as the majority believes that physician and family should paricipate in the preparaion of the DNR. Despite the frequency, it is observed that DNR texts coninue being strictly technical and of diicult understanding for the lay audience, besides having insuicient discussions among physicians and paients/family, delaying the treatment or not dealing with regular and uncomfortable situaions
which occur in the terminality of life, such as nau
-sea, ache, dehydraion, delirium, among others 24. In
this study it was observed that physicians are inter
-ested in discussing DNR, although unil this moment there areno speciic ethical direcives in Brazil, nor even about its form of preparaion.
It was veriied that, in this paper, physicians
prefer to discuss the DNR with relaives. In that as
-pect, another study 14 veriied that most intensivist
care physicians of Intensive Therapy Units (ITU) for burn paients would have preferred to take that decision alone, involving the family or the paient in smaller proporion; however, even then, the majority (81%) would respect the family’s opinion, corroboraing the results of this research. In the preparaion of the do not resuscitate order in ITU for burn paients, the medical team was involved in 88% of the cases registered, and the nursing team in 46%, but the paients’ families should always be involved,
as per the opinion of 66% of the physicians 14. The
tendency to seek engagement of physicians and rel
-aives for the decision was also evident in this study, followed by the inclusion of nursing professionals, a second-place alternaive.
The majority of the interviewees (56.25%) re
-ported that the decisions regarding DNR should be
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taken by the physician jointly with the family. An
-other study 25 conirmed that the paients’ wishes
about DNR were usually met, and, when they were not evident, it was the physician’s responsibility to
take the decision. On the other hand, the good com
-municaion between relaives and mulidisciplinary team members can be established with training and it consitutes a determining factor for the families’
saisfacion with paients in ITU and for the compli
-ance with of the paient’s will 26.
Almost the totality of the surveyed physicians
(93%) would accept the DNR of their relaives, per
-centage higher than the 62% 12 veriied among the
resident physicians of PUC’s Medical College of Sorocaba. It is esimated that the results’ variaion results from the diferent imes in which the survey
was done (2009 and 2014), relecing the chronolog
-ical change of percepion.
Few physicians would not desire to have their DNR respected in case of cardiorespiratory arrest when in a terminal stage of an illness. No explanaion was found for the fact, but it is esimated that eventually they prefer to leave that decision to the workmates, due to the diversity of factors which inluence the choice. It was observed that almost all physicians did not have a wish to be resuscitated in the situaions in
which there is indicaion (94%). But, in a study per
-formed with residents, that rate fell to 70% 12. In the
past an American physician with a metastaic cancer was subjected to several maneuvers of resuscitaion against his/her will and, ater much sufering, died
brainless, which has given rise to lots of quesions 27.
The adopion of non-resuscitaion in cas
-es which pr-esent clinical indicaion and paient’s consent consitutes the accomplishment of the
bioethics principle of nonmaleicence, consider
-ing that the measures to be taken would cause
more damages than beneits and would even con
-igure dysthanasia pracice. In that context, it is presumed that the current knowledge about the
adverse cardiorespiratory resuscitaion’s conse
-quences without a clinic indicaion has inluenced
the high rejecion of the procedures among the re
-searched paricipants.
Final Consideraions
The majority of the paricipaing physicians knew about the do not resuscitate order and agreed
to prescribe it, believed this to be the correct mo
-ment for regulaion and for the younger ones, the paient’s age was signiicant for the decision. Almost all physicians agreed in not resuscitaing relaives
in progressive illness terminal stage, upon their re
-quest and consent. The majority also considered
relevant the register of the DNR in the medical re
-cords, without the fear of being sued, and that the physician jointly with the family should take part in the decision.
The non-resuscitaion of paients in terminal stage progressive illness is a humanisic act which
aims to meet the bioethical principle of
nonmalef-icence with the primordial objecive of reducing
human distress and avoid the pracice of dystha
-nasia. The results found in this survey allows us to infer that it is a right moment for the preparaion of ethical direcives on the do not resuscitate order in Brazil, illing the exising regulaion gap in the law.
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Paricipaion of the authors
Elzio Luiz Putzel and Klisman Drescher Hilleshein have paricipated integrally in the research and in the wriing of the aricle. Elcio Luiz Bonamigo was the responsible for conducing the research and has paricipated in the wriing of the aricle. All authors have approved the inal wriing of the work.
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Appendix
Quesionnaire
1. Age:
2. Are you a medical specialist? If yes, which are your specialty?
3. Which is your workplace? a. ( ) Hospital
b. ( ) Primary Care Unit (UBS)
c. ( ) Mobile Urgency Care Service - Samu d. ( ) Private Clinic
4. Do you know the meaning of “Do Not Resuscitate Order”?
a. ( ) Yes b. ( ) No
5. In your opinion there are ethical direcives about “do not resuscitate order” in Brazil?
a. ( ) Yes b. ( ) No
6. In your professional acivity have you already
seen or have you had to assist a paient in a cardio
-respiratory arrest?
a. ( ) Yes b. ( ) No
7. If you were the assistant physician of terminal pa
-ient, would you prescribe or would you execute the ‘do not resuscitate order’?
a. ( ) Yes b. ( ) No
8. In your opinion, does the age of the paient inter
-fere in the decision-making for resuscitaing or not?
a. ( ) Yes b. ( ) No
9. Do you think it is appropriate in current imes that direcives on the ‘do not resuscitate order’ should exists or be prepared in Brazil?
a. ( ) Yes b. ( ) No
10. Do you consider important the register of the ‘do not resuscitate order’ in the medical records? a. ( ) Very important
b. ( ) Important
c. ( ) Of litle importance d. ( ) Without importance
11. In your opinion who should decide about the ‘do not resuscitate order’?
a. ( ) Physicians
b. ( ) Physicians and nurses c. ( ) Nurses
d. ( ) Physicians, nurses and family e. ( ) Family
f. ( ) Physicians and family
12. If your relaive were in a terminal situaion and/ or there were no available therapeuic condiions and it was his/her will not allowing the execuion of maneuvers of cardiopulmonary resuscitaion, would you be in favor of the ‘do not resuscitate order’?
a. ( ) Yes b. ( ) No
13. Can the physician be sued if he decides or takes
part in the ‘do not resuscitate order’ of a terminal
paient?
a. ( ) I completely agree b. ( ) I agree parially c. ( ) I disagree parially d. ( ) I completely disagree
14. If you were in a terminal stage of an incurable
disease, would you like that your anicipated direc
-ives of will be taken into consideraion, that is, the
desire of being resuscitated or not in case of cardio
-respiratory arrest?
a. ( ) Yes b. ( ) No
