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Internal medicine residents reported being less likely to consider certain aggressive interventions outside of CPR on patients with do not resuscitate (DNR) and do not intubate (DNI) orders, according to a study.
These findings have researchers worried about a trend of doctors ignoring patient preferences, especially those who may have DNRs but do not want to ignore other treatment options, according to Elizabeth K. Stevenson, MD, of the Division of Pulmonary and Critical Care Medicine, North Shore Medical Center, Salem, Mass., and her colleagues.
“DNR/DNI patients were less likely to receive many invasive procedures, surgical consultations, or transfer to the ICU,” wrote Dr. Stevenson and her colleagues. “[D]ecisions to withhold many types of care not specified in DNR/DNI orders is concerning, given that the majority of patients with a DNR/DNI status in registry studies indicated they would accept other interventions beyond CPR and intubation.”
Researchers surveyed 553 internal medicine residents in the United States using an Internet survey that presented four vignettes describing clinical situations. Participants were asked to rank how likely they would be to employ listed intervention methods, from “strongly agree” to “strongly disagree,” in each scenario (Ann Am Thorac Soc. 2017, Apr;14[4]:536-42).
Two different versions of the survey were randomly assigned, varying only in terms of which vignettes included patients with a DNR/DNI order.
Of the interventions listed for each scenario, decisions to transfer patients to the intensive care unit and suggest surgery consultations showed the strongest association with code status.
“Residents were significantly less likely to indicate they would provide invasive procedures (including central venous catheter placement, esophagogastroduodenoscopy, colonoscopy, bronchoscopy, dialysis, and surgery consultation) to patients who had a status of DNR/DNI compared with Full Code,” the investigators noted. “In contrast, decisions to pursue noninvasive diagnostic or therapeutic interventions (CT scans, administration of oxygen or intravenous fluids, blood cultures, and initiation of anticoagulation) did not significantly differ by patient code status, with high levels of use across all vignettes.”
In one vignette involving surgical consultation for an 80-year-old woman with septic shock secondary to Clostridium difficile infection, 89.1% of residents recommended a consult for full-care patients, while 77.7% recommended one for a patient with a DNR/DNI (P = .0008).
Despite these findings, 94%-96% of participants reported willingness to consult with patients on their preferences before treatment decisions, which Dr. Stevenson and her peers found somewhat comforting, although it did not completely assuage them.
“Although the ideal approach would be to have more comprehensive discussion and documentation of patients’ goals of care in the outpatient setting, realistically, many patients will neither have had such discussions nor [have] completed advance directives before hospitalization,” investigators wrote.
The study was limited by the size of the sample, which numbered approximately 2% of the active internal medicine residents in the United States. The researchers recognized that these scenarios were theoretical, and that practicing physicians may act differently when faced with a medical situation in real life. The study also was limited by the concentration of respondents within a single program, as shared experiences or teachers may cause similar responses to theoretical situations, they wrote.
One of the study’s authors reports grants from the National Institutes of Health. The other investigators report no relevant financial disclosures.
[email protected]
On Twitter @EAZTweets[polldaddy:9722880]
End-of-life treatment usually should be based on the preferences of the patients and how aggressive they want their physicians to be. Yet the study by Dr. Stevenson et al. shows that decisions in types of care are more often being based on the preferences of the doctors, which is very concerning. Engaging patients in a high-quality discussion of options and care preferences is an essential part of end-of-life treatment, and this trend of physician-attributable variation shows a level of paternalism that has no place in this type of care, and could lead to dire results for patients. For example, 72% of residents in one of the theoretical situations chose to intervene with dialysis in a full-code patient, while only 38% chose to do so for patients with a DNR. While the situations are theoretical, these findings uncover a disregard for patients’ autonomy in decisions about their own care. Since patients are unable to choose their own residents and many residents will not have the opportunity to consult with every patient, DNR patients are certainly vulnerable to the possibility of being assessed for treatment based on their code status. Residents are the future of medicine, and must be trained out of this habit so that patients’ preferences are not overlooked.
Joanna L. Hart, MD, is a research fellow in the Pulmonary, Allergy, and Critical Care Division, and the Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia. Meeta Prasad Kerlin, MD, MSCE, is the associate program director at the same institution. They had not disclosures. Their comments are in an editorial (Ann Am Thorac Soc. 2017 Apr;14[4]:491-2).
End-of-life treatment usually should be based on the preferences of the patients and how aggressive they want their physicians to be. Yet the study by Dr. Stevenson et al. shows that decisions in types of care are more often being based on the preferences of the doctors, which is very concerning. Engaging patients in a high-quality discussion of options and care preferences is an essential part of end-of-life treatment, and this trend of physician-attributable variation shows a level of paternalism that has no place in this type of care, and could lead to dire results for patients. For example, 72% of residents in one of the theoretical situations chose to intervene with dialysis in a full-code patient, while only 38% chose to do so for patients with a DNR. While the situations are theoretical, these findings uncover a disregard for patients’ autonomy in decisions about their own care. Since patients are unable to choose their own residents and many residents will not have the opportunity to consult with every patient, DNR patients are certainly vulnerable to the possibility of being assessed for treatment based on their code status. Residents are the future of medicine, and must be trained out of this habit so that patients’ preferences are not overlooked.
Joanna L. Hart, MD, is a research fellow in the Pulmonary, Allergy, and Critical Care Division, and the Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia. Meeta Prasad Kerlin, MD, MSCE, is the associate program director at the same institution. They had not disclosures. Their comments are in an editorial (Ann Am Thorac Soc. 2017 Apr;14[4]:491-2).
End-of-life treatment usually should be based on the preferences of the patients and how aggressive they want their physicians to be. Yet the study by Dr. Stevenson et al. shows that decisions in types of care are more often being based on the preferences of the doctors, which is very concerning. Engaging patients in a high-quality discussion of options and care preferences is an essential part of end-of-life treatment, and this trend of physician-attributable variation shows a level of paternalism that has no place in this type of care, and could lead to dire results for patients. For example, 72% of residents in one of the theoretical situations chose to intervene with dialysis in a full-code patient, while only 38% chose to do so for patients with a DNR. While the situations are theoretical, these findings uncover a disregard for patients’ autonomy in decisions about their own care. Since patients are unable to choose their own residents and many residents will not have the opportunity to consult with every patient, DNR patients are certainly vulnerable to the possibility of being assessed for treatment based on their code status. Residents are the future of medicine, and must be trained out of this habit so that patients’ preferences are not overlooked.
Joanna L. Hart, MD, is a research fellow in the Pulmonary, Allergy, and Critical Care Division, and the Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia. Meeta Prasad Kerlin, MD, MSCE, is the associate program director at the same institution. They had not disclosures. Their comments are in an editorial (Ann Am Thorac Soc. 2017 Apr;14[4]:491-2).
Internal medicine residents reported being less likely to consider certain aggressive interventions outside of CPR on patients with do not resuscitate (DNR) and do not intubate (DNI) orders, according to a study.
These findings have researchers worried about a trend of doctors ignoring patient preferences, especially those who may have DNRs but do not want to ignore other treatment options, according to Elizabeth K. Stevenson, MD, of the Division of Pulmonary and Critical Care Medicine, North Shore Medical Center, Salem, Mass., and her colleagues.
“DNR/DNI patients were less likely to receive many invasive procedures, surgical consultations, or transfer to the ICU,” wrote Dr. Stevenson and her colleagues. “[D]ecisions to withhold many types of care not specified in DNR/DNI orders is concerning, given that the majority of patients with a DNR/DNI status in registry studies indicated they would accept other interventions beyond CPR and intubation.”
Researchers surveyed 553 internal medicine residents in the United States using an Internet survey that presented four vignettes describing clinical situations. Participants were asked to rank how likely they would be to employ listed intervention methods, from “strongly agree” to “strongly disagree,” in each scenario (Ann Am Thorac Soc. 2017, Apr;14[4]:536-42).
Two different versions of the survey were randomly assigned, varying only in terms of which vignettes included patients with a DNR/DNI order.
Of the interventions listed for each scenario, decisions to transfer patients to the intensive care unit and suggest surgery consultations showed the strongest association with code status.
“Residents were significantly less likely to indicate they would provide invasive procedures (including central venous catheter placement, esophagogastroduodenoscopy, colonoscopy, bronchoscopy, dialysis, and surgery consultation) to patients who had a status of DNR/DNI compared with Full Code,” the investigators noted. “In contrast, decisions to pursue noninvasive diagnostic or therapeutic interventions (CT scans, administration of oxygen or intravenous fluids, blood cultures, and initiation of anticoagulation) did not significantly differ by patient code status, with high levels of use across all vignettes.”
In one vignette involving surgical consultation for an 80-year-old woman with septic shock secondary to Clostridium difficile infection, 89.1% of residents recommended a consult for full-care patients, while 77.7% recommended one for a patient with a DNR/DNI (P = .0008).
Despite these findings, 94%-96% of participants reported willingness to consult with patients on their preferences before treatment decisions, which Dr. Stevenson and her peers found somewhat comforting, although it did not completely assuage them.
“Although the ideal approach would be to have more comprehensive discussion and documentation of patients’ goals of care in the outpatient setting, realistically, many patients will neither have had such discussions nor [have] completed advance directives before hospitalization,” investigators wrote.
The study was limited by the size of the sample, which numbered approximately 2% of the active internal medicine residents in the United States. The researchers recognized that these scenarios were theoretical, and that practicing physicians may act differently when faced with a medical situation in real life. The study also was limited by the concentration of respondents within a single program, as shared experiences or teachers may cause similar responses to theoretical situations, they wrote.
One of the study’s authors reports grants from the National Institutes of Health. The other investigators report no relevant financial disclosures.
[email protected]
On Twitter @EAZTweets[polldaddy:9722880]
Internal medicine residents reported being less likely to consider certain aggressive interventions outside of CPR on patients with do not resuscitate (DNR) and do not intubate (DNI) orders, according to a study.
These findings have researchers worried about a trend of doctors ignoring patient preferences, especially those who may have DNRs but do not want to ignore other treatment options, according to Elizabeth K. Stevenson, MD, of the Division of Pulmonary and Critical Care Medicine, North Shore Medical Center, Salem, Mass., and her colleagues.
“DNR/DNI patients were less likely to receive many invasive procedures, surgical consultations, or transfer to the ICU,” wrote Dr. Stevenson and her colleagues. “[D]ecisions to withhold many types of care not specified in DNR/DNI orders is concerning, given that the majority of patients with a DNR/DNI status in registry studies indicated they would accept other interventions beyond CPR and intubation.”
Researchers surveyed 553 internal medicine residents in the United States using an Internet survey that presented four vignettes describing clinical situations. Participants were asked to rank how likely they would be to employ listed intervention methods, from “strongly agree” to “strongly disagree,” in each scenario (Ann Am Thorac Soc. 2017, Apr;14[4]:536-42).
Two different versions of the survey were randomly assigned, varying only in terms of which vignettes included patients with a DNR/DNI order.
Of the interventions listed for each scenario, decisions to transfer patients to the intensive care unit and suggest surgery consultations showed the strongest association with code status.
“Residents were significantly less likely to indicate they would provide invasive procedures (including central venous catheter placement, esophagogastroduodenoscopy, colonoscopy, bronchoscopy, dialysis, and surgery consultation) to patients who had a status of DNR/DNI compared with Full Code,” the investigators noted. “In contrast, decisions to pursue noninvasive diagnostic or therapeutic interventions (CT scans, administration of oxygen or intravenous fluids, blood cultures, and initiation of anticoagulation) did not significantly differ by patient code status, with high levels of use across all vignettes.”
In one vignette involving surgical consultation for an 80-year-old woman with septic shock secondary to Clostridium difficile infection, 89.1% of residents recommended a consult for full-care patients, while 77.7% recommended one for a patient with a DNR/DNI (P = .0008).
Despite these findings, 94%-96% of participants reported willingness to consult with patients on their preferences before treatment decisions, which Dr. Stevenson and her peers found somewhat comforting, although it did not completely assuage them.
“Although the ideal approach would be to have more comprehensive discussion and documentation of patients’ goals of care in the outpatient setting, realistically, many patients will neither have had such discussions nor [have] completed advance directives before hospitalization,” investigators wrote.
The study was limited by the size of the sample, which numbered approximately 2% of the active internal medicine residents in the United States. The researchers recognized that these scenarios were theoretical, and that practicing physicians may act differently when faced with a medical situation in real life. The study also was limited by the concentration of respondents within a single program, as shared experiences or teachers may cause similar responses to theoretical situations, they wrote.
One of the study’s authors reports grants from the National Institutes of Health. The other investigators report no relevant financial disclosures.
[email protected]
On Twitter @EAZTweets[polldaddy:9722880]
FROM ANNALS OF THE AMERICAN THORACIC SOCIETY
Key clinical point:
Major finding: Among 553 residents, patient code status was associated with invasive care decisions beyond intubation and CPR, especially transfers to the intensive care unit.
Data source: Randomized, cross-sectional Internet survey containing four clinical situations disseminated among internal medicine residents across the United States.
Disclosures: One of the study’s authors reports grants from the National Institutes of Health. The other investigators report no relevant financial disclosures.