Due to nurse involvement in status determination, nurses are inclined to recognize and appropriately manage factors that alter Do-Not-Resuscitate and Do-Not-Intubate (DNR/DNI) status. The factors presented in this study regarding DNR/DNI contribute to providing a high standard holistic approach to nursing. Methodological use of secondary analysis in ten qualitative studies using CINAHL database determined several contributing factors that influence DNR/DNI status. Various factors such as age, gender, religion, culture, medical diagnosis, educational level and race influence patient and family decisions concerning a patient’s DNR/DNI status. Implications include being aware of the numerous factors and implementing strategies to provide holistic care to patients and/or family when a DNR/DNI decision is being considered.
Age – the length of time a person has lived.
Culture awareness – a care provider’s knowledge about areas of cultural expression in which cultural groups differ
Religion – A belief in and reverence for a supernatural power or powers regarded as creator and governor of the universe.
Patient/Family perception – the view point or insight an individual has on a particular topic.
Race – a major division of humankind, having distinct physical characteristics.
Physician influence – the degree to which a doctor’s professional opinion effects patient’s decisions in healthcare.
Philosophical Factors- Personally specific beliefs about death and dying.
DNR/DNI – the choice to choose between life-saving measures or the choice to decline such life-saving measures.
|Factors Affecting Presence of DNR Orders|
|Factors||Effect on DNR Order|
|Age||DNR increase with increase age.|
|Culture||More Caucasians choose DNR/DNI status than minorities.|
|Patient/Familial Perception of Death||Those who view resuscitation as means of life restoration, and treatment less frequently have DNR orders. Those who view resuscitation as a painful procedure that is unnatural more frequently have DNR orders.|
|Religion||Religion plays an important role in DNR status.|
|Physicians Influence||No effect on frequency of DNR, however consumerist, paternalist, and doctor-as-agent models show how they come to a decision, and who is making the choice of DNR|
|Race||Pediatric: No effect||Adult: 14% of Caucasians, 37% of African Americans, & 42% of Hispanics wanted every life-saving measure, & did not desire DNR.|
Factors that Influence Patients DNR Status
B. Dillinger, C. Henry, B. McKinstry, & D. Oswalt
Arkansas Tech University Department of Nursing
1. Utilized CINAHL Database
≤ 5 y/o
Linked Full Text
DNR, DNI, Race, Advanced Directive, Age, & Religion
SIGNIFICANCE TO NURSING
The most important way to understand the needs of our patients, and thus how they perceive and make medical decisions near the end of life, is to strive to also know them as individuals within their larger social context.
What factors and to what extent do these factors influence DNR/DNI status with patients?
Altoff, J., Baker, J. N., Kane, J. R., Liu, W., Rai, S., Srivastava, K., & West, N. (2009, January). Race does not influence do-not-resuscitate status or the number or timing of end-of-life care discussions at a pediatric oncology referral center. Journal of Palliative Medicine, 12(1), 1-6. doi:10.1089/jpm.2008.0172.
Eliott, J., & Olver, I. (2008). Choosing between life And death: patient and family perceptions of the decision not to resuscitate the terminally ill cancer patient. Bioethics, 22 (3), 179-189. doi: 10.1111/j.1467-8519.2007.00620.x
Elliot, J. A., & Olver, I. (2011, July 22). Dying cancer patients talk about physician and patient roles in DNR decision making. Health Expectations, 14(2), 1-10. doi:10.1111/j.1369-7625.2010.00630.x
Loike, J., Ph.D., Gillick, M., M.D., Mayer, S., M.D., Prager, K., M.D., Simon, J. R., M.D., Steinberg, A., M.D., … Fischbach, R. L., Ph.D., M.P.E. (2010). The critical role of religion: caring for the dying. Journal of Palliative Medicine, 13(10), 1267-1271. doi: 10.1089/jpm.2010.0088
Wallace, M. P., Weiner, J. S., Pekmezaris, R., Almendral, A., Cosiquien, R., Auerbach, C., & Wolf-Klein, G. (2007). Physician cultural sensitivity in african american advance care planning: a pilot study. Journal of Palliative Medicine, 10(3), 721-727. doi: 10.1089/jpm.2006.0212
Personal factors contribute to a patient’s choice of DNR due to their personal interpretation of what a DNR/DNI status is. Patients see it as a choice between life and death.
The factor of religion and culture plays an important role in DNR/DNI status. For example, in Jewish Halakhic (law) culture, terminating ventilator life support is prohibited; however, in a circumstance where death is eminent, certain interventions such as vital signs, ventilator setting adjustments, etc., can be discontinued.
DNR patients generally desired less emotional burden on the family and concern with financial costs, whereas full code patients expected to remain in the care of their family.
Race is statistically insignificant in pediatric patients.
Personal beliefs about death and dying affect full code patients as they generally view resuscitation abstractly as a means to restore life and associate DNR orders with insufficient care or euthanasia.
Personal and philosophical beliefs about death and dying affect DNR patients as they view resuscitation with emphasis on suffering and associate DNR orders as a means to control pain, to increase comfort, and/or to allow for a natural dying process.
In 2011, Elliot and Oliver divided the DNR decision into 3 groups, consumerist, paternalist, or the doctor-as-agent model. In the consumerist model, which was the most popular choice, the DNR decision was strictly up to the patient. Two people out of 28 patients chose the paternalist model, or the physician decided model, while the other participants chose the physician-as-agent model. In the physician-as-agent model, the physician was able to decide DNR status given special circumstances, like a close personal relationship or friendship.
37% of African American, and 42% of Hispanics said they wanted every attempt to keep them alive regardless of how ill they were whereas only 14% of Caucasians wanted this option. (Wallace et al., 2007)
More whites agree to stop prolonged life saving measures than Hispanics and African Americans.(Wallace et al.,2007)
To investigate current research regarding factors that influence DNR/DNI status and to present nursing implications.