HOW DO MEDICAL RESIDENTS DISCUSS RESUSCITATION WITH PATIENTS

OBJECTIVE: To describe how medical residents discuss do-not-resuscitat e (DNR] orders with patients. DESIGN: Prospective observational study. SETTING: Inpatient medical wards of one university tertiary care cent er, one urban city public hospital, and one Veterans Affairs medical c enter. PARTICIPANTS: Thirty-one medical residents self-selected 31 of their English-speaking, competent patients, with whom they had DNR dis cussions. MEASUREMENTS: Three independent observers rated audiotaped d iscussions about DNR orders between the medical residents and their pa tients, Ratings assessed whether the physicians met standard criteria for requesting informed consent (e.g., disclosed the nature, benefits, risks, and outcomes), addressed the patients' values, and attended to the patients' emotional concerns. MAIN RESULTS: The physicians often did not provide essential information about cardiopulmonary resuscitat ion (CPR). While all the physicians mentioned mechanical ventilation, only 55% mentioned chest compressions and 32% mentioned intensive care , Only 13% of the physicians mentioned the patient's likelihood of sur vival after CPR, and no physician used a numerical estimate, The discu ssions lasted a median of 10 minutes and were dominated in speaking ti me by the physicians. The physicians initiated discussions about the p atients' personal values and goals of care in 10% of the cases, and mi ssed opportunities to do so. CONCLUSIONS: Medical ethicists, professio nal societies, and the public recommend more frequent discussions abou t DNR orders. Even when housestaff discuss resuscitation with patients , they may not be accomplishing the goal of increasing patient autonom y, Research and education must focus on improving the quality, as well as the quantity, of these discussions.