Knowledge and awareness regarding giving do-not-resuscitate orders among resident doctors in various intensive care units of a rural tertiary care center

Aditya Khandekar; Sourya Acharya; Samarth Shukla; Neema Acharya

doi:10.4103/jdmimsu.jdmimsu_118_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 15 | Issue : 3 | Page : 364-367

Knowledge and awareness regarding giving do-not-resuscitate orders among resident doctors in various intensive care units of a rural tertiary care center

Aditya Khandekar¹, Sourya Acharya², Samarth Shukla³, Neema Acharya⁴
¹ Intern, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India
² Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India
³ Department of Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India
⁴ Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India

Date of Submission	05-Aug-2019
Date of Decision	20-Aug-2020
Date of Acceptance	30-Aug-2020
Date of Web Publication	1-Feb-2021

Correspondence Address:
Dr. Aditya Khandekar
Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_118_19

Abstract

Background: Bioethics is a subject rarely taught, or discussed in residency. This can often result in a lack of awareness regarding patient rights and decision-making policies, especially amongst residents working in such high dependency units. To improve awareness regarding patient ethics, a study was thus conducted in AVBRH under the Dept. of Internal Medicine, to assess knowledge, aptitude and awareness of Residents working in Critical Care Units across the tertiary care centre. Aim and Objectives: To assess knowledge, aptitude and awareness of Residents working in Critical Care Units across the tertiary care centre. Methodology: The study was a cross-sectional study conducted across a period of two months, from 1^st April 2019 to 1^st June 2019. Study participants included 50 residents working in critical care units across multiple Departments of the Tertiary Care centre, with inclusion criteria being 1^st, 2^nd and 3^rd Year Junior residents who consented to participate in the study. Questionnaires were distributed to residents containing 10 multiple choice questions based on often-used terms with reagards to ethics, including DNR (Do Not resuscitate), 'respect of autonomy', and 'best interest standards' of a patient, and included clinical case scenarios on decision-making in emergency and ICU settings. On completion of filling of the questionnaire by all residents, data was entered into Microsoft Excel v. 2010, and responses were assessed based on percentages of residents that got each question right. Results: Results showed that while >50% residents scored correct answers on the clinical-based scenarios of critical care, aptitude regarding terminologies and decision-making ethics, including patient rights in such scenarios, needed considerable improvement, as no more than 30%. Conclusion: Thus, there is a need to inculcate bioethics-based learning into residency in today's times, which will directly result in better decision-making practices.

Keywords: Critical care, do-not-resuscitate, medical ethics, residents

How to cite this article:
Khandekar A, Acharya S, Shukla S, Acharya N. Knowledge and awareness regarding giving do-not-resuscitate orders among resident doctors in various intensive care units of a rural tertiary care center. J Datta Meghe Inst Med Sci Univ 2020;15:364-7

How to cite this URL:
Khandekar A, Acharya S, Shukla S, Acharya N. Knowledge and awareness regarding giving do-not-resuscitate orders among resident doctors in various intensive care units of a rural tertiary care center. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Feb 25];15:364-7. Available from: http://www.journaldmims.com/text.asp?2020/15/3/364/308538

Introduction

The most specific definition of the term “Bioethics” comes from the Convention for the Protection of Human Rights signed on April 4, 1997, in Oviedo, Spain, otherwise known as the Oviedo Convention. Bioethics, and specifically “Medical ethics,” encompasses the study of moral values and judgments applicable to medicine, with its four main components being respect for autonomy, beneficence, nonmaleficence, and justice. The oft-quoted Declaration of Geneva is a declaration of a physician's dedication to the humanitarian goals of medicine. The Declaration of Geneva was initially intended as a revision of the Hippocratic Oath to a formulation of that oath's moral truths that could be comprehended and acknowledged in a modern way, but is now considered a standalone declaration. In health-care settings, medical ethics is not frequently taught, or discussed in residency. This can often result in a lack of awareness regarding patient rights and decision-making policies, especially among residents working in such high-dependency units. With the advancement of health care and medical research, especially in today's times, doctors need to be aware of the basic ethical principles governing medicine because concerns are being raised about the possible threats to the known principles of ethics such as autonomy, beneficence, nonmalfeasance, and justice in the delivery of health care. Studies have revealed that deep shortcomings exist in the literature on medical ethics education. Deficits exist in all areas of the literature: (1) theoretical work done on the overall goals of medical ethics education, (2) empirical studies that attempt to examine outcomes for students, (3) studies examining teaching methods in medical ethics education, and (4) studies evaluating the effectiveness of various teaching methods.

Medical practitioners are expected to not only have the skills and knowledge relevant to respective fields of work, but also with the ethical and legal expectations that arise out of the standard clinical practice. To improve awareness regarding patient ethics, a study was thus conducted in AVBRH under the Department of Internal Medicine, to assess the knowledge, aptitude, and awareness of residents working in critical care units across the tertiary care center.^{[1],[2],[3],[4]}

Aim

The aim of this study is to assess the knowledge and awareness regarding giving do-not-resuscitate (DNR) orders among resident doctors in various intensive care units (ICUs) of a rural tertiary care center.

Objectives

The objectives of this study are as follows:

To determine the scope of providing DNR orders under several circumstances
To assess ethical aspects in consideration of DNR orders.

A questionnaire-based survey was conducted under the guidance of the Department of Medicine, AVBRH, Wardha, Maharashtra, India, from April 1, 2019, to June 1, 2019, for a period of 2 months.

Study setting

The study was conducted at Five ICUs of AVBRH and Shalinitai Meghe Superspeciality Center, comprising medicine ICU, surgical ICU, neuro ICU, pediatrics ICU, and the neonatal ICU.

Inclusion criteria

Fifty resident doctors from the departments of medicine, surgery, and pediatrics, working across ICUs in AVBRH.

Exclusion criteria

Residents who did not give consent to be part of the study
Residents who had not undergone a stipulated period of training in ICUs till the time of conduction of the study (including newly inducted junior residents).^{[5],[6],[7],[8],[9],[10]}

Methodology

Residents from each department were given a validated questionnaire based on the ethics guidelines by the Washington University School of Medicine, containing ten questions based on clinical scenarios. The responses were analyzed on spot and after completion, answer booklets were handed over, containing correct explanations regarding the ethical aspects of DNR orders. Opinions of resident doctors were further taken regarding how useful they found the questionnaire to be, and how much of an improvement they felt was added to their preexisting knowledge on DNR. The obtained data were then analyzed, and the results were calculated.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Jawaharlal Nehru Medical College, Sawangi(M), Wardha. Date: 31^st Oct 2017 with Reference no DMIMS(DU)/IEC/2017/802.

Results

When residents were asked as to who are the parties required to confirm a DNR order, only nine (18%) residents knew that all the three components are involved, i.e., the physician, the patient, and the surrogate decision maker need to consent to carry out a DNR. Next, the residents were asked what the term “AND” in the context of DNR refers to. Only 18 residents (36%) knew that AND refers to “Allow Natural Death.” When asked with regard to what the term “Respect of Autonomy” meant, only 35 residents (30%) knew that “Respect of Autonomy” is applicable only to respecting the rights of adult patients and their surrogates to make medical decisions. The next question included a scenario on advanced care planning, and the residents were asked to identify which scenario is it applicable to. Only 15 residents (30%) knew that advanced care planning is applicable only in case a patient is declared brain-dead. When asked on which of the following cannot be the surrogate decision maker of a patient, 37 residents (74%) answered correctly that an employer cannot be the autonomous decision maker for a patient.

On inquiring regarding the “Best interest standard,” only five residents (10%), and all of them from the department of pediatrics, knew that the best interest standard would be applied in the setting of a pediatric patient when the patient's parents/guardians act in the best interest anticipated. When the residents were asked regarding the following statement being true/false: “When cardiopulmonary resuscitation (CPR) does not have the potential to provide direct medical benefit, the physician may be officially justified in writing a DNR order and forgoing resuscitation,” only 16 residents (32%) answered correctly that the statement is false. Five residents (10%) knew that CPR may be withheld if it is expected to be ineffective, has minimal potential to provide direct medical benefit, or a patient with intact decision-making decides to forgo CPR. Only 14 residents (28%) knew that even details of disagreements need to be recorded in the medical records of a patient while writing a DNR order. Unfortunately, not a single resident (0%) knew that the terms “slow code” and “show code” are not emerging ethics regarding decision-making in scenarios involving CPR or variants of CPR used in specific clinical scenarios, but in fact improper and ineffective methods of delivering CPR, hence being violations of the trust between patients and health-care providers. The aforementioned data are represented in [Table 1].

Table 1: Components of medical ethics tested and the percentage of residents that answered correctly

Click here to view

Discussion

Stratta et al. report in the International Journal of Medical Education, significant erosion of ethics and a decline in patient empathy in residents progressing through their training years, as confessed by residents themselves. Pei et al. observed in developing world bioethics that consistent mentoring by senior consultants regarding the ethical aspects of patient care throughout the formative years of residency can significantly improve the outlook of junior doctors toward the same. Behrens and Fellingham present in the Journal of Clinical Research and Bioethics, a multi-centric project undertaken in hospitals across South Africa, which involved sensitization of residents toward patient care, and showed drastic improvement in results over a span of 2 years. Gordon and Winder in the Journal of Quality Health Care discussed similar training modules implemented in hospitals' ICUs across Britain, which are consistently showing encouraging results in pre- and postinterventional assessments. Resident doctors across the country today need to be sensitized further to the emotional needs of patients and caretakers as well, along with looking after just their physical well-being.^{[11],[12],[13],[14],[15],[16],[17]}

Conclusion

Thus, there is a need to inculcate bioethics-based learning into residency in today's times, especially among those who begin work in critical care setups during this period. This can improve the awareness of patient rights and directly result in better decision-making practices. Imparting thorough knowledge regarding the ethical and legal aspects of critical care is crucial, especially in today's times, with cases of medico-legal litigations increasing in frequency day by day.

This can be achieved by:

Conduction of regular continuing medical educations on a fortnightly-to-monthly frequency for all resident doctors
Provision of validated training modules comprising of in-depth knowledge regarding medical ethics, and
Compulsory inculcation of bioethics into the undergraduate and postgraduate curriculum at various levels of education.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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