title: Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life.
abstract: OBJECTIVE
  Controversy exists regarding whether the decision to pursue a do-not-resuscitate (DNR) order should be grounded in an ethic of patient autonomy or in the obligation to act in the patient's best interest (beneficence).
  
  
  OBJECTIVE
  To explore how physicians' approaches to DNR decision making at the end of life are shaped by institutional cultures and policies surrounding patient autonomy.
  
  
  METHODS
  We performed semistructured in-depth qualitative interviews of 58 internal medicine physicians from 4 academic medical centers (3 in the United States and 1 in the United Kingdom) by years of experience and medical subspecialty from March 7, 2013, through January 8, 2014. Hospitals were selected based on expected differences in hospital culture and variations in hospital policies regarding prioritization of autonomy vs best interest.
  
  
  METHODS
  This study identified the key influences of institutional culture and policies on physicians' attitudes toward patient autonomy in DNR decision making at the end of life.
  
  
  RESULTS
  A hospital's prioritization of autonomy vs best interest as reflected in institutional culture and policy appeared to influence the way that physician trainees conceptualized patient autonomy. This finding may have influenced the degree of choice and recommendations physician trainees were willing to offer regarding DNR decision making. Trainees at hospitals where policies and culture prioritized autonomy-focused approaches appeared to have an unreflective deference to autonomy and felt compelled to offer the choice of resuscitation neutrally in all situations regardless of whether they believed resuscitation to be clinically appropriate. In contrast, trainees at hospitals where policies and culture prioritized best-interest-focused approaches appeared to be more comfortable recommending against resuscitation in situations where survival was unlikely. Experienced physicians at all sites similarly did not exclusively allow their actions to be defined by policies and institutional culture and were willing to make recommendations against resuscitation if they believed it would be futile.
  
  
  CONCLUSIONS
  Institutional cultures and policies might influence how physician trainees develop their professional attitudes toward autonomy and their willingness to make recommendations regarding the decision to implement a DNR order. A singular focus on autonomy might inadvertently undermine patient care by depriving patients and surrogates of the professional guidance needed to make critical end of life decisions.
authors.affiliation: Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland2Program in Palliative Care, Johns Hopkins School of Medicine, Baltimore, Maryland3Primary Care Unit, Department of Public Health and Primary Care, University of C.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Dzeng
authors.affiliation: Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Colaianni
authors.affiliation: Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.
authors.forename: Martin
authors.initials: M
authors.lastname: Roland
authors.affiliation: Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Geetanjali
authors.initials: G
authors.lastname: Chander
authors.affiliation: Program in Palliative Care, Johns Hopkins School of Medicine, Baltimore, Maryland4Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Smith
authors.affiliation: Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Kelly
authors.affiliation: Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.
authors.forename: Stephen
authors.initials: S
authors.lastname: Barclay
authors.affiliation: Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: David
authors.initials: D
authors.lastname: Levine
mesh_terms: D001291:Attitude of Health Personnel; D003657:Decision Making; D004991:Ethics, Institutional; D018578:Hospital-Physician Relations; D006801:Humans; D016134:Organizational Policy; D028701:Patient Rights; D026684:Personal Autonomy; D010817:Physician-Patient Relations / Q000941:ethics*; D010820:Physicians / Q000941:ethics / Q000523:psychology; D036301:Qualitative Research; D016414:Resuscitation Orders / Q000941:ethics / Q000523:psychology; D013727:Terminal Care / Q000941:ethics / Q000523:psychology; D006113:United Kingdom; D014481:United States