title: Themes and variations: An exploratory international investigation into resuscitation decision-making.
abstract: Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made in hospitals throughout the globe. International variation in clinicians' perception of DNACPR decision-making and implementation and the factors influencing such variation has not previously been explored.
  
  
  
  A questionnaire asking how DNACPR decisions are made, communicated and perceived in their country was composed: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had 4 weeks to answer the questionnaire.
  
  
  
  78 responses (44%) were received from 43 countries. All continents were represented. 88% of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. 94% of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes towards death, medical education and culture, health economics and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions.
  
  
  
  The majority of countries surveyed make some form of DNACPR decision but differing cultures and economic status contribute towards a heterogeneity of approaches to resuscitation decision-making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision-making and implementation.
authors.affiliation: Gonville & Caius College, University of Cambridge, Cambridge, UK.
authors.forename: Alexander J O
authors.initials: AJO
authors.lastname: Gibbs
authors.affiliation: Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK.
authors.forename: Alexandra C
authors.initials: AC
authors.lastname: Malyon
authors.affiliation: Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK; Warwick Medical School, University of Warwick Coventry, CV4 7AL, UK. Electronic address: zoe.fritz@addenbrookes.nhs.uk.
authors.forename: Zoë B McC
authors.initials: ZBM
authors.lastname: Fritz
mesh_terms: D001291:Attitude of Health Personnel; D001293:Attitude to Death; D016887:Cardiopulmonary Resuscitation / Q000592:standards*; D003142:Communication; D003657:Decision Making; D006801:Humans; D010820:Physicians / Q000523:psychology*; D017410:Practice Guidelines as Topic; D016414:Resuscitation Orders; D011795:Surveys and Questionnaires; D013727:Terminal Care
keywords: International perspectives; Physician–patient relationship; Resuscitation decisions; Resuscitation orders