Has the Pendulum Swung too Far in Favor of Patient Autonomy?

"Institutional Culture and Policies’ Influence on Do Not Resuscitate Decision-Making at the End of Life," online first in JAMA Internal Medicine looks at the difference between (a) hospitals which have policies or a culture that prioritizes patient autonomy with regard to DNAR orders and (b) hospitals where doctors’ recommendations on what might be in patients’ best interests medically hold more sway.



Elizabeth Dzeng and colleagues argue that UK hospitals currently differ from the more consumer-oriented approach of their US counterparts and doctors' recommendations still hold sway over DNAR decisions. However, they are moving more towards the US model as the recent case of Janet Tracey at Addenbrookes hospital in Cambridge shows. Tracey’s family successfully sued the hospital over a DNR order that was implemented without the family's permission.



The authors interviewed 58 doctors and trainees at three academic medical centers in the US and one in the UK. Trainee doctors at hospitals with emphasized patient autonomy often felt compelled to offer the choice of resuscitation in a neutral way in all situations regardless of whether they believed it would be clinically appropriate. 



In contrast, trainees at hospitals where policies and culture prioritized best interest-focused approaches felt more comfortable recommending against resuscitation in situations where survival was unlikely. They felt confident, for instance, to discourage the ineffective use of CPR and found it ethically suspect to offer CPR in futile situations such as for frail elderly patients with incurable metastatic cancer where doing CPR may result in broken ribs and electric shocks as well as depriving them of a dignified death.



Unlike trainees, experienced doctors at all hospitals were willing to make recommendations against resuscitation if they believed it would be futile. 



The authors conclude: "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."  (HT: University of Cambridge)