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Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life.

Abstract：

IMPORTANCE:Controversy exists regarding whether the decision to pursue a do-not-resuscitate (DNR) order should be grounded in an ethic of patient autonomy or in the obligation to act in the patient's best interest (beneficence). OBJECTIVE:To explore how physicians' approaches to DNR decision making at the end of life are shaped by institutional cultures and policies surrounding patient autonomy. DESIGN, SETTING, AND PARTICIPANTS:We performed semistructured in-depth qualitative interviews of 58 internal medicine physicians from 4 academic medical centers (3 in the United States and 1 in the United Kingdom) by years of experience and medical subspecialty from March 7, 2013, through January 8, 2014. Hospitals were selected based on expected differences in hospital culture and variations in hospital policies regarding prioritization of autonomy vs best interest. MAIN OUTCOMES AND MEASURES:This study identified the key influences of institutional culture and policies on physicians' attitudes toward patient autonomy in DNR decision making at the end of life. RESULTS:A hospital's prioritization of autonomy vs best interest as reflected in institutional culture and policy appeared to influence the way that physician trainees conceptualized patient autonomy. This finding may have influenced the degree of choice and recommendations physician trainees were willing to offer regarding DNR decision making. Trainees at hospitals where policies and culture prioritized autonomy-focused approaches appeared to have an unreflective deference to autonomy and felt compelled to offer the choice of resuscitation neutrally in all situations regardless of whether they believed resuscitation to be clinically appropriate. In contrast, trainees at hospitals where policies and culture prioritized best-interest-focused approaches appeared to be more comfortable recommending against resuscitation in situations where survival was unlikely. Experienced physicians at all sites similarly did not exclusively allow their actions to be defined by policies and institutional culture and were willing to make recommendations against resuscitation if they believed it would be futile. CONCLUSIONS AND RELEVANCE:Institutional cultures and policies might influence how physician trainees develop their professional attitudes toward autonomy and their willingness to make recommendations regarding the decision to implement a DNR order. A singular focus on autonomy might inadvertently undermine patient care by depriving patients and surrogates of the professional guidance needed to make critical end of life decisions.

journal_name

JAMA Intern Med

journal_title

JAMA internal medicine

authors

Dzeng E,Colaianni A,Roland M,Chander G,Smith TJ,Kelly MP,Barclay S,Levine D

doi

10.1001/jamainternmed.2015.0295

subject

Has Abstract

pub_date

2015-05-01 00:00:00

pages

812-9

issue

eissn

2168-6106

issn

2168-6114

pii

2212265

journal_volume

175

pub_type

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Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life.