Physicians’ Experiences of Do-Not-Resuscitate (DNR) Orders in Hematology and Oncology Care – A Qualitative Study

Abstract

Objective: In oncology and hematology care, a patient can have such a poor prognosis that cardiopulmonary resuscitation (CPR) for cardiac arrest is not considered feasible. The responsible physician can then decide to apply a do-not-resuscitate (DNR) order, meaning that neither basic (heart compressions and ventilation) nor advanced (defibrillator or medicines) CPR should be performed. Previous research has found disagreement in relation to DNR decisions among physicians and nurses working in this field. The aim of the present study was to explore the experiences and perceptions of physicians with respect to DNR orders within hematology and oncology care, in order to better understand their specific roles in this decision-making process, with focus on the ethical aspects of the decisions. Methods: Individual interviews were performed with 16 physicians working in hematology and oncology departments at seven hospitals in Sweden. Data were analyzed using systematic text condensation (STC). Results: Two main parts of the data were discerned. The first described the physicians’ different roles in the team in relation to decisions on DNR, as decision maker, patient advocate and mediator for relatives and team member. In the second part the physicians shared their experiences of making ethically challenging decisions on DNR. The experiences ranged from feeling as though they were making themselves God, to regarding a DNR order as one regular medical decision among others. The physicians made decisions on CPR or DNR with the patient's best interests in mind, primarily on medical grounds. However, they also considered ethical aspects of the decision, weighing beneficence versus maleficence. Conclusion: The results indicate that DNR decisions in oncology and hematology care are not only taken on medical grounds, such as the prognosis of the disease and the expected survival after CPR, but also with reference to ethical values, such as patient autonomy and the quality of life after resuscitation.