Documente Academic
Documente Profesional
Documente Cultură
Nursing Ethics 18(6) 802813 The Author(s) 2011 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733011410093 nej.sagepub.com
Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it
Young-Rye Park
Kunsan National University, Republic of Korea
Jin-A Kim
Korea Health Industry Development Institute, Republic of Korea
Kisook Kim
Changwon National University, Republic of Korea
Abstract This study investigated the perceptions and attitudes of ICU nurses towards the do not resuscitate (DNR) decision and changes in their nursing activities after implementation of the DNR decision in South Korea. A data survey was conducted in South Korea between August and October 2008, with a convenience sample of 252 ICU nurses who had more than one year of clinical experience. The data were collected via a self-administered questionnaire. Most of the nurses perceived the necessity of the DNR decision in cases where there would be no chance of patient recovery despite massive efforts. Very few of the nurses activities changed, either passively or actively, after implementation of the DNR decision. Moreover, the findings of this research provide suggestions for the future direction of the DNR decision and ethical nursing guidelines in South Korea. Further investigations are needed for the development of decision-making skills and intervention guidelines for end-of-life nursing. Keywords do not resuscitate, ethics, intensive care unit nurses, perceptions
Introduction
The quantitative and qualitative development of modern medicine has contributed much to the prolongation of life through life-support systems, not only as a result of improvements in general health and the average life span, but also in the number of cases for whom medical treatment is considered useless.1 In particular, since the first successful cardiopulmonary resuscitation by massage of the outside of the heart following cardiac arrest in the early 1960s in the USA, cardiopulmonary
Corresponding author: Kisook Kim, Department of Nursing, Changwon National University, #9 sarim-dong, Changwon, Gyeongnam 641-773, Republic of Korea Email: kskim2011@changwon.ac.kr
Park et al
803
resuscitation (CPR) is now considered for all patients with cardiac arrest.2,3 However, not all patients who are resuscitated via CPR recover sufficiently to leave the hospital. Even in intensive care units (ICUs) with state-of-the-art monitoring systems, the report for 24-hour survival rate after successful CPR is only 9.2%.4 Indeed, there is currently considerable debate surrounding the use of CPR in patients with end-stage disease, some believing that it extends the patients life at the expense of the quality of life (i.e. such patients often suffer intense pain), and delays the expected process of death by merely maintaining heart and lung functions.3,5 In such cases, bearing in mind the chances of patient recovery and quality of life, the medical team and the patients family may choose to implement the do not resuscitate (DNR) decision.6 The concept underlying the increase in the implementation of the DNR decision is that the patients dignity is insulted if life-support treatment is continued despite the negligible (or zero) chances of recovery.7 Patients with serious conditions are treated in ICUs, and many biomedical problems of dying patients are encountered, with the DNR agreement most often being proposed by doctors.1 However, the exclusion of nurses from the DNR decision-making process may prevent them from playing their role as patient advocates, and make it difficult to consult and support the patients family. Nurses spend most of their time beside patients, and through effective communication with their patients and their families can play an important role in discerning their beliefs, values and wishes with regard to the ethical conclusions.8 Therefore, considering the environmental characteristics of the ICU, where visits from family members or caregivers are restricted and the patients critical health condition can rapidly deteriorate, establishing a value system and understanding about the DNR decision-making process among ICU nurses would be invaluable. Since DNR decisions involve the suspension or reservation of treatment from the patient, they may cause the doctors and nurses to do less than their best for the patients and to essentially give up on them, and so the decision and follow-up treatment or nursing should be carefully considered.9,10 The ethical problems related to this arise not only in making the DNR decision, but also in the changes made to the medical interventions and nursing activities associated with the patient after the decision is made. It has been reported that such medical interventions and nursing activities tend to be reduced after the DNR decision has been implemented.911 However, there has been little research into the development of ethical guidelines with regard to making the DNR decision, and the nursing activities implemented thereafter by the nurses in the ICU. In addition, the decision to implement the DNR protocol for dying patients is one of the most important issues influencing the relationship between the medical team and the patients caregivers. Some more-advanced countries have developed guidelines for the DNR decision and end-of-life care that are applicable to their own cultures, and have implemented ethical education. Such guidelines do not exist in South Korea, despite being needed.1 In response to this, a group of medical professionals in South Korea has announced the foundation of a special committee for establishing guidelines regarding the withdrawal of life-sustaining treatment; this committee has arranged a practical guide and provided ethical decision-making guidelines for each hospital and medical team.12 The use of these guidelines has resulted in the resolution of at least some of the ethical conflicts experienced by nurses in various medical environments13. However, it falls short with regard to specific methods that can help nurses, who take charge of the nursing and have an important impact on the familys decision making, to make a DNR decision and withdraw life-sustaining treatment based on nursing ethics. The aim of the present study was to determine the perceptions and attitudes of ICU nurses in South Korea towards DNR, and changes in their nursing activities after implementing the DNR decision. Based on these results, we discuss the current health-care situation with respect to the DNR decision in South Korea and other countries.
804
Instruments
We measured the following parameters: The nurses perceptions towards DNR. These were assessed using an instrument with 10 questions, plus one open-ended question, which was developed by Han et al.,14 and modified and supplemented by Kang.15 This instrument evaluated nurses general perceptions regarding DNR, such as its necessity and reasons for its selection, and the nurses preferences regarding DNR when confronted with making the decision for themselves. The ethical attitudes towards DNR. These were evaluated based on the tools of Lee et al.12 and Ko16. Using 19 questions, the nurses ethical attitudes about DNR were determined by asking questions relating to human life and the nursing field; there were three possible responses to these questions: agree, disagree and dont know. Various DNR-related cases were described, and the nurses responded to them with their own opinions. Cronbachs a for this part of the questionnaire was 0.64. The changes in nursing activities. These were induced by the implementation of the DNR decision, as measured by Jang.9 The activities questioned included basic nursing interventions such as morning care, tracheal suction, intravenous (IV) monitoring, communication and reporting the patients condition. The nurses were asked to check the degree to which these activities changed after the DNR decision was made, reflecting their experiences. It was composed of 17 questions totally, and measured the change in nursing activities asking no change, more passive, more active, regular or not applicable (N/A). Cronbachs a for this part of the questionnaire was 0.96.
Data analysis
The collected data were analysed using SPSS 15.0 software. Frequencies and percentages were calculated from the data to evaluate the subjects general characteristics, perceptions of DNR, ethical attitudes and the change in their nursing activities after the DNR decision is made.
Park et al
805
Table 1. Demographic characteristics (n252) Characteristics Age Categories 2029 years 3039 years 40 and more Less than 3 years 35 years Over 5 years Less than 3 years 35 years Over 5 years Medical ICUs Surgical ICUs Others Staff Nurse Charge Nurse Head Nurse Have None Married Unmarried Associate degree Bachelors degree Masters degree and higher Yes No Yes No n (%) 213 (84.5) 37 (14.7) 2 (0.8) 115 (45.6) 59 (23.4) 78 (31.0) 135 (53.6) 58 (23.0) 59 (23.4) 96 (38.1) 117 (46.4) 39 (15.5) 240 (95.2) 9 (3.6) 3 (1.2) 141 (56.0) 111 (44.0) 33 (13.1) 219 (86.9) 115 (45.6) 127 (50.4) 10 (4.0) 62 (24.6) 190 (75.4) 202 (80.2) 50 (19.8)
Years of RN experience
Position
806
Table 2. Nurses Perceptions of DNR (n 252) Items Necessity of DNR Categories
n (%) 242 (96.0) 10 (4.0) 116 (46.0) 129 (51.2) 7 (2.8) 57 (22.6) 133 (52.8) 54 (21.4) 8 (3.2) 53 (21.0%) 14 (5.6) 129 (51.2) 22 (8.7) 34 (13.5) 250 (99.2) 2 (0.8) 51 (20.2) 76 (30.2) 71 (28.2) 54 (21.4) 137 (54.4) 28 (11.1) 87 (34.5) 235 (93.2) 6 (2.4) 11 (4.4) 80 (31.7) 12 (4.8) 158 (62.7) 2 (0.8) 139 (55.2) 9 (3.6) 104 (41.2)
Yes No Reason for necessity of DNR Comfort and a dignified death Terminal medical condition Medical cost saving Responsible decision maker for DNR Patient only Patient and family Family and physician Others Reason for unnecessary of DNR Duty for health care provider Legal issues Uncertain of decision time Uncertain of responsible decision maker Potential negligence of treatment or nursing care Necessity of explaining about DNR to patient and family Yes No Appropriate time to explain about DNR When the patient is admited to ICU When the patient becomes comatose When the patient stops self-respiration Others Increased nursing needs after explanation about DNR Yes No I do not know Necessity of DNR guideline Yes No I do not know Intention to make DNR decision for a member of my family Yes No Up to the situation Others Intention to DNR decision for myself Yes No Up to the situation
almost all of the subjects (n 250, 99.2%) answered that explanations of DNR are necessary. With regard to the appropriate time for that explanation, 76 nurses (30.2%) answered when the patient becomes comatose, followed by when the patient stops self-respiration (n 71, 28.2%), and when the patient is admitted to the ICU (n 51, 20.2%). As for the intention to make the DNR decision, 158 nurses (62.7%) would consider DNR (depending on the medical condition) for a member of their family, and 139 (55.2%) would agree to DNR for themselves.
Park et al
Table 3. Ethical attitudes toward DNR (n 252) No 1 2 Contents The patients wish should be accepted when he or she is aware of a terminal medical condition and refuse treatment and care If the family wants, mechanical ventilator should be withdrawn in unconscious patients who are dependent upon it to sustain their life Even the dying patient should continue to be extended to live by almost all available methods The DNR decision should be made by the attending physician who is fully aware of the patients medical condition If the patients does not want it, DNR should not be implemented for any medical condition Medical staff should perform CPR on a patient in emergency situation although there is no hope of surviving if DNR decision is not made. Medical staff should do their best in other treatments although CPR is held in DNR patients Medical staff should always inform to the patient about his/her condition when there is no hope of surviving. Nurses should explain the bare fact to the patients and their family The condition should be explained frankly to them despite causing shock in case of condition near to death Family should be with a patient in ICU when DNR decision is made. The mechanical ventilator should be used at a minimum after declaration of DNR. The DNR decision must be made based on the DNR guidelines The familys requests should be respected if they want aggressive treatment such as CPR at the point of death even after the DNR decision has been made Basic nursing care should be minimized for the patients physical and psychological comfort after declaration of DNR Nurse should advise immediately when he/she observes that a nurse colleague does not apply aseptic techniques in DNR patients. Nurse should notify the physician about the DNR patients condition whenever it changes. It is natural for physician to decrease the concerns about patients after DNR decision is made. Nurse should advocate for the family who complain about decreased physicians concerns in DNR patients. Agree n (%) 193 (76.6) 73 (29.0) Do not know n (%) 42 (16.7) 100 (39.7)
807
3 4 5 6
7 8 9 10 11 12 13 14
111 (44.0) 128 (50.8) 174 (69.0) 191 (75.8) 80 (31.7) 85 (33.7) 193 (76.6) 185 (73.4)
15 16
40 (15.9) 22 (8.7)
17 18 19
implemented for any medical condition. In terms of the familys wishes, 185 nurses (73.4%) agreed that the familys requests should be respected if they want aggressive treatment such as CPR at the point of death, even after the DNR decision has been made. Meanwhile, only 73 nurses (29.0%) agreed that if the family wants, mechanical ventilator should be withdrawn in unconscious patients who are dependent upon it to sustain their life.
808
Table 4. Changes in Nursing activities after making the DNR decision (n 252) Items Bed making Morning Care Tracheal suction Chest percussion Position change and prevention care for pressure ulcer Pressure ulcer and wound care Simple massage CVP monitoring Vital Sign monitoring Body temperature control and hot/cold pack apply IV fluid monitoring and management Electrolyte monitoring / acid-alkali management Management of drain tubes Infection management Routine change of invasive lines Reporting the patients condition Active communication with family
No change More passive More active Irregular n (%) n (%) n (%) n (%) 186 (73.8) 186 (73.8) 188 (74.6) 162 (64.3) 170 (67.5) 174 (69.0) 163 (64.7) 106 (42.1) 161 (63.9) 169 (67.1) 168 (66.7) 125 (49.6) 181 (71.8) 178 (70.6) 183 (72.6) 130 (51.6) 134 (53.2) 21 (8.3) 22 (8.7) 12 (4.8) 44 (17.5) 37 (14.7) 32 (12.7) 49 (19.4) 95 (37.7) 42 (16.7) 39 (15.5) 35 (13.9) 82 (32.5) 27 (10.7) 29 (11.5) 23 (9.1) 74 (29.4) 44 (17.5) 34 (13.5) 40 (15.9) 50 (19.8) 37 (14.7) 41 (16.3) 41 (16.3) 31 (12.3) 27 (10.7) 37 (14.7) 41 (16.3) 44 (17.5) 28 (11.1) 36 (14.3) 43 (17.1) 43 (17.1) 35 (13.9) 56 (22.2) 11 (4.4) 3 (1.2) 2 (0.8) 9 (3.6) 4 (1.6) 5 (2.0) 8 (3.2) 18 (7.1) 11 (4.4) 2 (0.8) 3 (1.2) 16 (6.3) 7 (2.8) 2 (0.8) 3 (1.2) 13 (5.2) 18 (17.1)
With respect to making the DNR decision, while 193 nurses (76.6%) agreed that the DNR decision must be made based on the DNR guidelines, only 56 nurses (22.2%) agreed that the DNR decision should be made by the attending physician who is fully aware of the patients medical condition. As to the question of the range of treatments, 111 nurses (44.0%) answered that medical staff should do their best in other treatments, even when CPR is withheld in DNR patients. As for basic nursing care, only 42 nurses (16.7%) agreed that basic nursing care should be minimized for the patients physical and psychological comfort after declaration of DNR. The breakdown of the responses to the statement the mechanical ventilator should be used at a minimum after declaration of DNR was as follows: agree (33.7%), dont know (36.5%) and disagree (29.8%).
Discussion
The ethical perceptions and attitudes of ICU nurses towards DNR were investigated, and changes in nursing activities after the DNR has been made were determined in order to establish guidelines for nurses ethical
Park et al
809
decision making for DNR. Most (80.2%) of the nurses in the present cohort had experience of DNR, which is lower than the 92% in the study of Lee et al.12 However, 75.4% had experienced ethical education in the year preceding commencement of the study, which is higher than the 34.5% of general duty nurses12 and 43% of ICU nurses16 in previous studies. This suggests that education on ethics is increasing with the increased interest in social issues and the trend towards enhancing morality. This may be regarded as the effect of in-service education or other educations implemented as a result of highlighting the necessity of ethical education in nursing practice where ethical decision making is needed.
810
dont know or disagree to the question as to the types of treatment a DNR patient should receive. This suggests that there are changes in attitude towards DNR-determined patients, which will be discussed later; 16.7% of our subjects agreed that if DNR is declared, basic nursing care should be diminished for the patients comfort. Almost all subjects agreed that CPR should be performed on a dying patient who suffers a sudden heart attack and who needs CPR, but who had not made any decision regarding DNR. As to gaining agreement from the patient/family to DNR, 69% and 75.8% agreed to the statements that nurses should explain the bare facts to the patient and their family and the condition should be explained frankly to them, despite the shock, in cases where the patient is near to death, respectively. These rates are a little higher than those found in previous studies, whereby 45.157.0% of the subjects agreed that they had a duty to explain the DNR concept to patients and their families. Moreover, this painful process is considered desirable, based on the principal of respect for autonomy. There was ethical conflict among the nurses, as evidenced by the various reactions to questions related to the inclination of doctors and nurses to be relatively disinterested in their DNR patients.
Park et al
811
hold an important position for supporting and helping the patients family; they should therefore be able to provide proper nursing to the family of patients in a critical condition by continual and consistent interactions with them.
Study limitations
This research was conducted using a convenience sample of nurses working in the ICUs of general hospitals in specific regions, and as such its results cannot be generalized. Moreover, the lack of differences and relationships with the variables and subjects observed herein could be attributable to the basic instruments used, which were developed for a small cohort. Therefore, further research into the ethical implementation of the DNR directive is required.
Conclusion
The results of the present survey of ICU nurses perceptions and attitudes towards DNR revealed that most of them understood the necessity for the DNR directive in cases where the patient will not ultimately survive irrespective of treatment efforts. Regarding implementation of the DNR directive, the nurses believed that the will of patients and their family members is of utmost importance, and that it would be inevitable that they would have to explain the
812
DNR directive to them. In addition, they thought that patients opinions should be accepted when they reject the treatment, when they are aware of the hopelessness of their condition, and that the treatment range for DNR patients should be to do their best with the exception of providing CPR. The nurses felt that emergent CPR should be applied to patients who have not had DNR explained to them, and that the information should be reported to both the family members and their patients, with basic treatment being continued even after making the DNR decision. The changes in nursing activities to a patient with a DNR directive are reduced passively to CVP monitoring, electrolyte monitoring, acidbase management and reporting on the patients condition, but nursing activities such as active communication with the patients family, tracheal suction and IV fluid monitoring are actively increased compared to before implementing DNR. Nurses perceptions and attitudes towards the DNR decision and the changes in nursing activities after implementing it were surveyed, and the direction for future work has been discussed. However, because this study was limited to a clinical selection of a specific region, we suggest that further research on nursing ethics related to the end of life in a more extensive region and more varied nursing departments is required. The development of guidelines adapted to clinical practice through such research will help nurses to act wisely when they are presented with ethical conflicts. Conflict of interest statement The authors declare that there is no conflict of interest. References
1. Lee KH, Jang HJ, Hong SB, Lim CM and Koh YS. Do-not-resuscitate order in patients, who were deceased in a medical intensive care unit of an University hospital in Korea. Korean J Crit Care Med 2008; 23: 849. 2. American Heart Association. Introduction to the international guidelines 2000 for CPR and ECC. Circulation 2000; 102 (suppl.): 111. 3. Lee YB. Nurses and Doctors perceptions, experiences, and ethical attitudes on DNR. Clin Nurs Res 2007; 13: 73 85. 4. Myrianthefs P, Kalafati M, Lemonidou C, Minasidou E, Evegelopoulou P, Karatzas S and Baltopoulos G. Efficacy of CPR in a general, adult ICU. Resuscitation 2003; 57: 438. 5. Ebell MH. Practical guidelines for Do Not Resuscitation Orders. Am Fam Physician 1994; 50: 12939. 6. Wilson M. Highlighting the role of policy in nursing practice through a comparison of DNR policy influences and no CPR decision influences. Nurs Outlook 1996; 44: 2729. 7. Byrd C. Do-Not-Resuscitate(DNR) orders. Prog Cardiovasc Nurs 1994; 9: 456. 8. Hilden H, Louhiala P, Honkasalo M and Palo J. Finnish nurses views on end-of-life discussions and a comparison with physicians view. Nurs Ethics 2004; 11: 16578. 9. Jang SO. Experience of family with DNR and change of care after DNR decision-making in intensive care units [Thesis]. Kyeong Sang University, Korea, 2000. 10. Kim SH. Decision making process in Do-Not-Resuscitate orders for patients with cancer. Korean J Nurs Query 2005; 13: 12743. 11. Zimmerman JE, Knaus WA, Sharp SM, Anderson AS, Draper EA and Wagner DP. The use and implication of Do Not Resuscitate Orders in intensive care units. J Am Med Assoc 1996; 255: 3516. 12. Special committee for establish guideline of withdrawal of life-sustaining treatment. Guidelines of withdrawal of life-sustaining treatment. Korean Medical Association Homepage. http://www.kma.org/contents/board/ mboard.asp?execview&strBoardIDreport&intSeq3849 (2009, accessed August 2010). 13. Lee SH, Kim JS, Hwang MJ, Hwang BD and Park YJ. Ethical dilemma associated with DNR: The attitude of clinical nurse. Clin Nurs Res 1998; 4: 14762.
Park et al
813
14. Han SS, Chung SA, Moon MS, Han MH and Ko GH. Nurses understanding and attitude on DNR. J Korean Nurs Admin Acad Soc 2001; 7: 40314. 15. Kang HI. Awareness and experience of nurses and physicians on DNR [Thesis]. Hallym University, Chun-Cheon, Korea, 2003. 16. Ko HJ. A study on ethical attitude of nurses about DNR and change in nursing activities after DNR decision [Thesis]. Chosun University, Gwang-Ju, Korea, 2004. 17. Sherman DA and Branum K. Critical care nurses perceptions of appropriate care of the patient with orders not to resuscitate. Heart Lung 1995; 24: 3219. 18. Gillick MR. Advance care planning. N Engl J Med 2004; 350: 78. 19. Dyer C. High court says advance directives are binding. Brit Med J 1992; 305: 6023. 20. Miyata H, Shiraish H and Kai I. Survey of the general publics attitudes toward advance directives in Japan: How to respect patients preferences. BMC Med Ethics 2006; 7: 11. 21. Kim SY, Kang HH, Koh Y and Koh SO. Attitudes and practices of critical care physicians in end-of-life decision in Korean intensive care units. Korean J Med Ethics 2009; 12 :1528.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.