Hostname: page-component-cd9895bd7-dzt6s Total loading time: 0 Render date: 2024-12-23T18:20:46.274Z Has data issue: false hasContentIssue false
  • English
  • Français

The surrogate's experience in authorizing a do not resuscitate order

Published online by Cambridge University Press:  19 February 2008

Catherine M. Handy ,
Daniel P. Sulmasy ,
Cindy K. Merkel  and
Wayne A. Ury
Catherine M. Handy
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York
Daniel P. Sulmasy*
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York New York Medical College, Valhalla, New York
Cindy K. Merkel
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York
Wayne A. Ury
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York New York Medical College, Valhalla, New York
*
Address correspondences and reprint requests to: Daniel P. Sulmasy, John J. Conley Department of Ethics, St. Vincent's Hospital Manhattan, 153 W. 11th St., New York, NY 10011. E-mail: daniel_sulmasy@nymc.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

Little is known about the subjective experience of surrogates who authorize do not resuscitate (DNR) orders. This experience seems especially acute in settings such as New York State, where patients and surrogates generally give written consent for DNR orders. The goal of this study is to investigate the subjective and emotional experience of surrogates who authorize DNR orders in this setting.

Methods:

A qualitative, phenomenological research design was used. Surrogates of patients on the medical service were approached no earlier than 1 day and no later than 7 days after authorizing a DNR order. The interview guide was open-ended and included general prompts. Interviews were taped and transcribed. Researchers then coded the transcripts and examined the data for clusters of themes. They then met to discuss and recode disagreements.

Results:

Saturation was met after 10 subjects were interviewed. The following major surrogate themes were found: (1) Signing a DNR order is a process, not an isolated act. (2) The presence or absence of good quality communication and psychological support from health care personnel are among the most important factors in this process. (3) The process of signing a DNR order can raise many negative emotions including guilt, ambivalence, and conflict. (4) Prior discussions, documents such as living wills, and consensus among family members make it easier to determine the patient's wishes and carry them out by signing the DNR. (5) The surrogates believed that signing a DNR order is a prerequisite to obtaining adequate opioid analgesia.

Significance of results:

The experience of authorizing a DNR order is a complex and emotional decision-making process. Evidence of the patient's prior wishes and support from health care personnel make the process easier. It is disconcerting that surrogates viewed DNR orders as a prerequisite to obtaining relief for a patient's pain or suffering.

Keywords

SurrogateCommunicationDo not resuscitate ordersEthicsEnd-of-life care
Type
Original Articles
Information
Palliative & Supportive Care , Volume 6 , Issue 1 , March 2008 , pp. 13 - 19
Copyright
Copyright © Cambridge University Press 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

Dimond, E.P. (1994). Two years of the patient self-determination act. Oncology Nursing: Patient Treatment and Support, 1, 1–14.Google Scholar
Ersek, M., Kagawa-Singer, M., Barnes, D., et al. (1998). Multicultural considerations in the use of advance directives. Oncology Nursing Forum, 25, 1683–1690.Google ScholarPubMed
Hansen, L.C., Danis, M., Mutran, E., et al. (1994). Impact of patient competence on decisions to use or withhold life-sustaining treatment. American Journal of Medicine, 97, 235–241.CrossRefGoogle Scholar
Hare, J., Pratt, J.C., & Nelson, C. (1992). Agreementbetween patients and their self-selected surrogates on difficult medical decisions. Archives of Internal Medicine, 152, 1049–1054.CrossRefGoogle Scholar
Hull, S.C., Taylor, H.A., & Kass, N.E. (2001). Qualitative methods. In Methods in Medical Ethics, Sugarman, J. & Sulmasy, D.P. (eds.), pp. 146–158. Washington, DC: Georgetown University Press.Google Scholar
Jacobs, D.A. (1998). Family members' experiences with decision-making for incompetent patients in the ICU: A qualitative study. American Journal of Critical Care, 7, 30–36.CrossRefGoogle Scholar
Jezewski, M.A. & Finnell, D.S. (1998). The meaning of DNR status: Oncology nurses experiences with patients and families. Cancer Nursing, 21, 212–221.CrossRefGoogle ScholarPubMed
Layde, P.M., Beam, C.A., Broste, S.K., et al. (1995). Surrogates predictions of seriously ill patients' resuscitation preferences. Archives of Family Medicine, 4, 518–523.CrossRefGoogle ScholarPubMed
Lederberg, M.S. (1997). Doctors in limbo: The United States ‘DNR’ debate. Psychooncology, 6, 321–328.3.0.CO;2-#>CrossRefGoogle ScholarPubMed
Morse, J.M., ed. (1989). Qualitative Nursing Research: A Contemporary Dialogue. Rockville, MD: Aspen Publishers.Google Scholar
New York Public Health Law Article 29-B (Section 405.43 of Title 10 of the Codes, Rules, and Regulations of the State of New York). (1987).Google Scholar
Oiler, C. (1998). Phenomenology: The method. In Nursing Research: A Qualitative Perspective, Munhall, P., & Oiler, C. (eds.), pp. 69–84. Norwalk, CT: Appleton-Century-Crofts.Google Scholar
Oklahoma Do Not Resuscitate Act. (2005). 63 Okl. St. § 3131.5.Google Scholar
Rein, A.J., Harshman, D.L., Frick, T., et al. (1996). Advance directive decision making among medical inpatients. Journal of Professional Nursing, 12, 39–42.CrossRefGoogle ScholarPubMed
Spiegelberg, H. (1979). The Phenomenological Movement. New York: Holt, Rinehart and Winston.Google Scholar
Sulmasy, D.P., Dwyer, M., & Marx, E. (1996). Do the ward notes reflect the quality of end-of-life care? Journal of Medical Ethics, 22, 344–348..CrossRefGoogle ScholarPubMed
Sulmasy, D.P., Sood, J.R., Texeira, K., et al. (2006). Prospective trial of a new policy eliminating signed consent for Do Not Resuscitate orders. Journal of General Internal Medicine, 21, 1261–1268.CrossRefGoogle ScholarPubMed
Sulmasy, D.P., Terry, P.B., Weisman, C.S., et al. (1998). The accuracy of substituted judgments in patients with terminal diagnoses. Annals of Internal Medicine, 128, 621–629.CrossRefGoogle ScholarPubMed
Tilden, V.P., Tolle, S.W., Nelson, C.A., et al. (2001). Family decision making to withdraw life-sustaining treatments from hospitalized patients. Nursing Research, 50, 105–115.CrossRefGoogle ScholarPubMed
Wenger, N.S., Oye, R.K., Bellamy, P.E., et al. (1994). Prior capacity of patients lacking decision making ability early in hospitalization: Implications for advance directive administration. The SUPPORT Investigators Study to Understand Prognoses and Preferences for Outcomes Risks of Treatments. Journal of General Internal Medicine, 9, 539–543.CrossRefGoogle ScholarPubMed