The following article discusses the use of cardiopulmonary resuscitation, especially in regards to patients who are critically ill.
STATEMENT OF THE PROBLEM
Cardiopulmonary resuscitation is a common practice in health care setting world wide. However, the use of cardiopulmonary resuscitation was called on questions (Brindley, Markland, Mayers, & Kutsogiannis, 2002; Deep, Griffith, & Wilson, 2008; Löfmark, 2000). Cardiopulmonary resuscitation would be abusive treatment when it performs on patients who are critically ill. Among patients with cancer, the survival rate after performing CPR was found to be as low as sixteen percent (Brett, 2001). Moreover, CPR left many patients significantly impaired (Hilberman, Kutner, Parsons, & Murphy, 1997).
Furthermore, the ethic of justice calls for the need to identify which treatment would be beneficial for patients (Hilberman et al., 1997). Justice requires not to waste health care setting resources especially when these resources are scarce as the case in many health care setting In Jordan. Performing CPR for patient with low chance of survival is nothing but wasting of health care setting resources and time consuming for health are providers. Therefore, DNR seems to be the solution for relieving patients' and health care providers suffering, as well as, saving the resources of health care setting when resuscitation as a life-saving measure seems to be unsuccessful.
Therefore, the low survival rate after performing CPR combined with the pressure to contain medical costs created an ethical question if we should always perform CPR. For example, is it justifiable to do CPR for those patients who are critically ill, or have poor quality of life? Hence, It is crucial to shift care modalities from resuscitate orders to Do not resuscitate (DNR) orders for those patients who had a low chance of survival after CPR.
I. PROJECT GOALS AND OBJECTIVES
The purpose of this study is to explore and describes the attitude and practices of Jordanian physician and nurses toward DNR orders.
Specific objectives include:
- Identify nurses and physicians attitude toward DNR orders
- Determine the current practices of nurses and physicians surrounding DNR orders
This study is aiming to answer the following research questions:
- What is Jordanian nurses and physicians' attitude toward DNR orders?
- What factors affect nurses and physicians attitudes toward DNR orders?
- Do nurses' attitudes toward DNR orders differ from physicians' attitudes?
Definition of related terms:
- Do-not-resuscitate (DNR): is a written instruction from the physicians to the medical staff not to try to revive the patient if breathing or heart beat has stopped (Dunn, 2000).
- Attitudes: Are the individual overall evaluation (favourable or unfavourable feelings) of the object or behaviour, that is, the beliefs that performing the behaviour will lead to certain consequences, and the evaluation of these consequences (Fishbein & Ajzen, 1975).
Do-not-resuscitate (DNR) orders have become popular over the past few decades in western countries (Sham et al., 2007). Do-not -resuscitate means to not initiate a cardiopulmonary resuscitation at the time of cardiac or respiratory arrest. The principle of the DNR is based on the thought of whether resuscitation is appropriate or not in terms of patients` conditions and their quality of life. The decision to do-not-resuscitate is a very complex decision and raises many ethical and legal concerns. For example, despite the extensive discussion of DNR orders health care providers have difficulties in deciding when to make those decisions and who should be consulted before DNR is written. Moreover, many health care providers seem to lack the knowledge about the legal and ethical meaning of DNR orders (Rakas, 2008)
What might complicate the DNR decisions is the fact that many interacting factors seem to influence those decisions. These factors including but not limited to patients` preferences, probability of survival after CPR, and expected quality of life before and after performing CPR (Sham et al., 2007). Moreover, several studies have found that health care providers' attitudes and preferences have an impact on their decisions toward DNR orders (Kelly, Eliasson, Stocker, & Hnatiuk, 2002; Löfmark, 2000). Physicians and nurses seem to be uncertain about the ethics and the decision process of DNR orders (Löfmark, 2000). Findings thus far suggest that there are differences in the practice of DNR orders, which might be related to the variances on the attitudes and knowledge of health care providers; therefore, it would be worthwhile to examine nurses and physicians attitudes towards DNR.
REVIEW AND ANALYSIS OF RELATED WORK
Despite the widespread of the do-not-resuscitate practices world wide, several studies have revealed that those decisions differ between different health care settings (Granja, Teixeira-Pinto, & Costa-Pereira, 2001; Kelly et al., 2002). Guidelines regarding do-not resuscitate orders emphasize the fact that those orders should be based on patients preferences (Chao, 2002; Granja et al., 2001; Venneman, Narnor-Harris, Perish, & Hamilton, 2008). However, several studies have found that even when patients are capable of making their own decisions, they rarely participate in DNR orders (Chao, 2002; Granja et al., 2001; Hosaka et al., 1999; Manias, 1998), whereby it is found to be related to several factors (Granja et al., 2001; Kelly et al., 2002). These include physicians` specialties , patients` age, patients` diagnoses, and patients` quality of life(Kelly et al., 2002). Further more, studies have revealed that DNR orders differ between health care providers (Chao, 2002; Granja et al., 2001; Kelly et al., 2002; Vincent, 1999) and there appears to be strong evidence that health care providers seem to be reluctant to initiate or carry out a discussion about DNR orders (Eliasson, Howard, Torrington, Dillard, & Phillips, 1997; Hosaka et al., 1999; Kelly et al., 2002), which is found to be related to different factors as physician`s specialty.
Physicians with different specialty have different perspective toward DNR orders. Kelly et al. (2002) found that pulmonary critical care physicians are more likely to recommend DNR order than cardiologist and general internist. Further more, physicians` age and physicians with more years of experiences are more likely to recommend DNR orders as well as those who claimed to have a strong religious background also found to influence the decision to withdraw resuscitative effort (Kelly et al., 2002)(Kelly, 2002). In regards to gender, A study by Sulmasy, He, McAuley and Ury (2008) found that men are more confident than women in their recommendations for DNR orders.
Despite the vital role nurses play in the process of making a DNR orders few studies have looked at nurses’ role and attitudes toward DNR orders (Sulmasy et al., 2008). However, most studies have found that nurses either have limited involvement on the decision making or they are uncertain about their abilities to initiate discussions with patients and their families regarding DNR orders (Hosaka et al., 1999; Sulmasy et al., 2008). In a descriptive study to examine health care professional beliefs and attitudes the process of DNR orders, Sulmasy et al. found that nurses are more likely than physicians to believe that they should initiate a discussion about DNR orders. Further, they found that nurses had more positive attitudes and were more confident in their abilities to discuss DNR orders than physicians. Similarly, Manias (1998) found that ninety one percent of the nurses agreed that nurses should be involved in determining the patients` DNR status. However, nurses believe that physicians usually are the one who are responsible for deciding whether to initiate CPR or not (Manias, 1998; Sulmasy et al., 2008)
SIGNIFICANCE OF WORK
Despite the wide discussion of DNR order in the literature no single study was done in Jordan. Therefore, it is of interest to investigate the practice of DNR in Jordan. The current study would highlight the need for opening the discussion of DNR orders as a replacement of aggressive resuscitation for those patients who had low chance of survival. Health care providers need to think of do-not resuscitate orders instead of resuscitation for those patients who they belief that they will less likely to survive after performing CPR.
There are two arms for the significant of the study. First, with regard to the national aspect, whereby there is no study about DNR orders among Jordanian health care providers, this study would help in understanding Jordanian health care providers' attitudes and practices regarding DNR order. Moreover, the findings from this study could be a good use for clinician and health care policy maker in evaluating the practice of DNR in their hospitals.
Second, with regard to the international facet, and since most of the studies were conducted in the Western countries, giving that Jordan is one of Eastern countries- countries with different culture, and beliefs-, this study would provide thorough information about the practice of DNR in different culture as well as improving patients' quality of life worldwide. Finally this study is significant because it would open different and interesting approaches for future studies.
III. PLAN OF WORK 1. Methodology
A descriptive cross sectional design will be used in this study to examine the attitude of nurses and physicians towards DNR orders and their confidence of discussing and practices of DNR with family or relatives.
Sample and settings:
Convenient sampling will be utilized. All nurses and physicians who are licensed to practice nursing and medicine, and working at either public or private hospitals are eligible to participate in the current study. Nurses and physicians at different working areas, with different specialties, and different years of experiences will be recruited.
The setting for the current study will be the accessible private and public hospitals in the two biggest cities in Jordan (Amman and Irbid). The participants will be recruited from hospitals that will show interest and will give the approval to conduct the study.
Using conventional power analysis of medium effect size, a power of .8 and a level of significance at .05, and t test for independents groups; the estimated sample size will be 64 participants for each groups (nurses and physicians) with a total sample of 168 participants (Cohen, 1992). However, over sampling is intended to get more insight.
In the current study Salmosy et al Decision Making for the seriously ill questionnaire will be utilized. The original questionnaire consists of three components, which includes: confidence regarding the DNR discussion, attitudes regarding DNR discussion, and demographic characteristics. The total number of items is 35 items, with a 5 point Likert scale. The items worded on positive and negative direction, however, the negative worded items will be recoded. Though, the total items’ score means positive attitude and more confidence with the DNR order content validity was established by the author. However, the psychometric properties for the instrument will be tested in the current study. The questionnaire was modified to meet the study purposes and to accommodate the culture differences. The modification includes deleting items that don’t fit the Jordanian culture as “I think that this hospital has a good policy for complying with the New York,” or adding items that found on the literature to be crucial in exploring attitudes toward DNR orders as “patient requires the same level of care after the do-not-resuscitate order as is initiated,” (see attachment). The questionnaire has two forms, one for physicians and the other one for nurses.
Data collection method and procedures:
After obtaining the approval of the institutional Review Board at Jordan University of Science and Technology and hospital administrator, participants will be approached by the investigators. Each participant will receive a cover letter (see attachment) explaining the purposes of the study as well as assuring them their participation is voluntary, they can withdraw at any time and all the information will be confidential and anonymous. Completing the questionnaire and returning it implied participants’ approval.
Descriptive statistics (means, standard deviations, etc) will be used to determine the characteristics of the participants as well as to answer the first two research questions; what is Jordanian nurses and physicians` attitude toward DNR orders? and what factors affect nurses and physicians attitude toward DNR orders? t-test will be used to answer the third research question (do nurses differ in their attitude and knowledge regarding DNR orders from physicians?)
2. Location and Safety Considerations
This study is a descriptive one. Therefore, no harm will be expected from conducting this study. However, as mentioned earlier the IRB approval of Jordan University of Science and Technology will be obtained before conducting the study.
3. Available Resources
Library and internet access are available to the researcher as well as personal computers.
4. Expected Results/Outputs
It is anticipated that the health care providers hold different attitudes toward DNR orders. It is anticipated that health care providers attitude toward DNR order will be influenced by their religious and cultural values. The researchers hope and anticipated that this study will open the door for further researches and discussions. The result of the project hopefully will be published to the public to help improve the end of life care in Jordan.
Brindley, P. G., Markland, D. M., Mayers, I., & Kutsogiannis, D. J. (2002). Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ, 167(4), 343-348.
Chao, C.-S. C. (2002). Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan. Journal of Nursing Research: JNR, 10(3), 161-167.
Deep, K. S., Griffith, C. H., & Wilson, J. F. (2008). Discussing preferences for cardiopulmonary resuscitation: What do resident physicians and their hospitalized patients think was decided? Patient Education and Counseling, 72(1), 20-25.
Dunn, M. C. (2000). Attitudes of medical personnel toward do-not-resuscitate orders. Unpublished M.S.W., California State University, Long Beach, United States -- California.
Eliasson, A. H., Howard, R. S., Torrington, K. G., Dillard, T. A., & Phillips, Y. Y. (1997). Do-not-resuscitate decisions in the medical ICU: comparing physician and nurse opinions. Chest, 111(4), 1106-1111.
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior: An introduction to theory and research. London: Addison-Wesley.
Granja, C., Teixeira-Pinto, A., & Costa-Pereira, A. (2001). Attitudes towards do-not-resuscitate decisions: differences among health professionals in a Portuguese hospital. Intensive Care Medicine, 27(3), 555-558.
Hilberman, M., Kutner, J., Parsons, D., & Murphy, D. J. (1997). Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)[see comment]. Journal of Medical Ethics, 23(6), 361-367.
Hosaka, T., Nagano, H., Inomata, C., Kobayashi, I., Miyamoto, T., Tamai, Y., et al. (1999). Nurses' perspectives concerning do-not-resuscitate (DNR) orders. Tokai Journal of Experimental & Clinical Medicine, 24(1), 29-34.
Kelly, W. F. M. D., Eliasson, A. H. M. D., Stocker, D. J. M. D., & Hnatiuk, O. W. M. D. (2002). Do Specialists Differ on Do-Not-Resuscitate Decisions?*. Chest, 121(3), 957-963.
Löfmark, R. (2000). Do-not-resuscitate orders. Ethical aspects on decision making and communication among physicians, nurses, patients and relatives. Lund University, Lund.
Manias, E. (1998). Australian nurses' experiences and attitudes in the "Do Not Resuscitate" decision. Research in Nursing & Health, 21(5), 429-441.
Rakas, S. (2008). Physician and nurses' perceptions of DNR's in the Emergency Department. Unpublished M.S., D'Youville College, United States -- New York.
Sham, C. O., Cheng, Y. W., Ho, K. W., Lai, P. H., Lo, L. W., Wan, H. L., et al. (2007). Do-not-resuscitate decision: the attitudes of medical and non-medical students. Journal of Medical Ethics, 33(5), 261-265.
Sulmasy, D., He, M., McAuley, R., & Ury, W. (2008). Beliefs and attitudes of nurses and physicians about do not resuscitate orders and who should speak to patients and families about them. Critical Care Medicine, 36(6), 1817-1822.
Venneman, S. S., Narnor-Harris, P., Perish, M., & Hamilton, M. (2008). "Allow natural death" versus "do not resuscitate": three words that can change a life. J Med Ethics, 34(1), 2-6.
Vincent, J. (1999). Forgoing life support in western European intensive care units: The results of an ethical questionnaire. Critical Care Medicine, 27(8), 1626-1633.
V. DISCUSS ANY RELATED ETHICAL ISSUES
As mentioned earlier after obtaining the approval of the institutional Review Board at Jordan University of Science and Technology and hospital administrator, participants will be approached by the investigators. Each participant will receive a cover letter explaining the purposes of the study as well as assuring them their participation is voluntary, they can withdraw at any time and all the information will be confidential and anonymous. Completing the questionnaire and returning it implied participants’ approval.