2009 Southern Regional Meeting Abstracts

Purpose of Study: Healthcare providers may have different opinions about the appropriate level of care for patients with a do-not-resuscitate (DNR) order. These beliefs can cause disagreement among members of the care team.
Methods Used: We surveyed adult acute care nurses about perceived appropriateness of treatments provided to patients with a DNR order. Nurses rated 12 therapeutic interventions on an 4-point Likert scale. Interventions included IV fluids, ICU transfers, and mechanical ventilation. Respondents were asked to describe a situation where there were differences between healthcare providers about appropriate treatment for a patient. Data was analyzed using SAS with descriptive statistics and correlation matrices. Two independent raters performed content analysis of the open response data via an iterative process to develop themes.
Summary of Results: 113 nurses completed the survey for a response rate of 40%. The sample included 58% critical care nurses, with a mean of 9.9±9.6 years of experience. The majority of respondents felt that it was probably or very appropriate for patients with DNR orders to receive IV fluids (92%) and tube feeding (81%). Only half of respondents felt that transfer to the ICU was appropriate. The treatment modalities rated least appropriate were elective mechanical ventilation (36%) and elective cardioversion (39%). Nurses with more years of experience were less likely to rate tube feeding (-0.38) or to transfer to the ICU (-0.43) as appropriate (p<0.01). The open-response question was answered by 53 respondents. Disagreements about care usually occurred with physicians (23) most often when the plan included invasive treatments the nurse felt were inappropriate (17). Nine situations involved physicians pursuing more invasive care than the patient or family wanted. We identified several etiologies for these disagreements including the perceived balance of benefit versus burden of treatment, physician inexperience, and resource use.
Conclusions: Nurses have widely varying beliefs on what treatments are appropriate for a patient with a DNR order. They experience disagreements with physicians about appropriate care for patients near the end of life, often out of concern for the burdens placed on the patient and family.