title: 'Do not attempt resuscitation' and 'cardiopulmonary resuscitation' in an inpatient setting: factors influencing physicians' decisions in Switzerland.
abstract: OBJECTIVE
  To determine the prevalence of cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) orders, to define factors associated with CPR/DNAR orders and to explore how physicians make and document these decisions.
  
  
  METHODS
  We prospectively reviewed CPR/DNAR forms of 1,446 patients admitted to the General Internal Medicine Department of the Geneva University Hospitals, a tertiary-care teaching hospital in Switzerland. We additionally administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion.
  
  
  RESULTS
  21.2% of the patients had a DNAR order, 61.7% a CPR order and 17.1% had neither. The two main factors associated with DNAR orders were a worse prognosis and/or a worse quality of life. Others factors were an older age, cancer and psychiatric diagnoses, and the absence of decision-making capacity. Residents gave four major justifications for DNAR orders: important comorbid conditions (34%), the patients' or their family's resuscitation preferences (18%), the patients' age (14.2%), and the absence of decision-making capacity (8%). Residents who wrote DNAR orders were more experienced. In many of the DNAR or CPR forms (19.8 and 16%, respectively), the order was written using a variety of formulations. For 24% of the residents, the distinction between the resuscitation order and the care objective was not clear. 38% of the residents found the resuscitation form useful.
  
  
  CONCLUSIONS
  Patients' prognosis and quality of life were the two main independent factors associated with CPR/DNAR orders. However, in the majority of cases, residents evaluated prognosis only intuitively, and quality of life without involving the patients. The distinction between CPR/DNAR orders and the care objectives was not always clear. Specific training regarding CPR/DNAR orders is necessary to improve the CPR/DNAR decision process used by physicians.
authors.affiliation: Department of General Internal Medicine, Geneva University Hospitals, Switzerland.
authors.forename: Maria
authors.initials: M
authors.lastname: Becerra
authors.forename: Samia A
authors.initials: SA
authors.lastname: Hurst
authors.forename: Noelle
authors.initials: N
authors.lastname: Junod Perron
authors.forename: Stéphane
authors.initials: S
authors.lastname: Cochet
authors.forename: Bernice S
authors.initials: BS
authors.lastname: Elger
mesh_terms: D000328:Adult; D000368:Aged; D001293:Attitude to Death; D016887:Cardiopulmonary Resuscitation / Q000941:ethics / Q000523:psychology; D016638:Critical Illness / Q000523:psychology*; D003657:Decision Making / Q000941:ethics; D028741:Ethics Committees, Clinical / Q000706:statistics & numerical data; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D007297:Inpatients / Q000523:psychology; D008297:Male; D018447:Medical Futility / Q000941:ethics / Q000331:legislation & jurisprudence / Q000523:psychology; D008875:Middle Aged; D010820:Physicians / Q000523:psychology*; D011379:Prognosis; D011788:Quality of Life / Q000523:psychology*; D016414:Resuscitation Orders / Q000941:ethics / Q000331:legislation & jurisprudence / Q000523:psychology; D013557:Switzerland