Resuscitation.
22 (1991)
Elsevier Scientific
229
229-235
Publishers
Ireland
Ltd
Resuscitation attitudes among medical personnel: How much do we really want to be done? Joseph
“Department
of
Emergency sity Medical
Varon”,
Medicine,
George L. Sternbachb, Arthur H. Combsd
SIOZC,
Medicine
Service,
Center,
Stanford, Care Area,
Associate
Providence
resuscitation
Hospital.
July 28th.
Professor
of Surgery,
of‘Medicine, Depurrmenl
Professor
CA 94305 und “Associate
(Received
Cardiopulmonary
hClinicul
“Associate
Peter Rudd’ and
Clinical
WashinKron.
1991: Accepted
(CPR) is attempted
Profkwr
of Medicine
DC 20017
August
Departmml
of Medicine. i U.S. A.
(!f Surgery.
Stanjbrd Director.
UniverCritiurl
I
19th. 1991)
every day. Whereas
medical professionals
and per-
sonnel perform these resuscitation attempts. no previous studies have reported the attitudes of medical personnel towards resuscitation for themselves. We have attempted to assess the prevalent attitudes among various physicians at various levels in training and nurses. An eleven item questionnaire was sent to medical students, house officers. attending physicians and registered nurses at university medical centers. Each questionnaire consisted of respondent’s sociodemographic information. their attitudes about CPR for themselves and their beliefs about outcome after CPR with particular disease states. The results were analyzed using chi-square analysis. Four hundred questionnaires were mailed and 240 were returned (6@% response rate). All groups favored resuscitation in a university hospital over other sites (P < 0.05). More nurses requested to be ‘no code’ compared with other professionals (P < 0.005). Attending physicians requested that CPR attempts be terminated after less time than any other group (P < 0.005). Medical students requested resuscitation significantly more than any other group in the presence of terminal conditions such as metastatic cancer, acquired immunodeficiency syndrome and severe chrome obstructive pulmonary disease (P < 0.005). Medical personnel’s beliefs about CPR may be influenced by their experiences with particular patients and events. As trainees acquire more experience they appear less inclined to desire resuscitation efforts for themselves. Attitudes
- Cardiopulmonary
resuscitation
- Code status
- Housestaff
- Resuscitation
INTRODUCTION
Sudden cardiac death accounts for 400 000-600 000 deaths each year in the United States [I]. Attempting resuscitation from cardiopulmonary arrest is an everyday event. Modern external cardiopulmonary resuscitation (CPR) began in the 1950’s with documentation of how basic life support could succeed [2]. Its use expanded throughout American hospitals in the 1960’s and early 1970’s [3]. Success rates for inpatient and outpatient CPR (defined as those patients leaving the hospital Address all correspondence
Baylor College of Medicine.
und reprint
requests
One Baylor
to: Joseph
Plaza.
0300-9572/911$03.50 0 199 I Elsevier Scientific Printed and Published in Ireland
Houston, Publishers
Varon. Pulmonary and Critical TX 77030. U.S.A. Ireland
Ltd
Care Section.
230
alive) have varied from O-30% [4,5]. Enthusiasm based on results in sudden cardiac death have led to the development of intensive campaigns to train and recertify both lay persons and medical personnel in basic and advanced cardiac life support. To determine the attitudes of medical personnel towards resuscitation for themselves, we conducted a survey of medical students, residents, attending physicians and nurses. We were specifically interested in their desires and expectations of CPR should they sustain a cardiac arrest and in their prediction of the effectiveness of CPR in selected patient populations. MATERIALS
AND
METHODS
We developed and distributed a two page, eleven item, questionnaire students, housestaff, attending physicians and nurses over (February-August, 1990). Survey
to medical 7 months
administration
We obtained the names and home addresses of medical students (all levels), house officers (internal medicine, surgery, pulmonary, oncology), attending physicians (general internal medicine and medical subspecialties) and general medicine ward nurses at Stanford University School of Medicine (Stanford, CA), Palo Alto VA Medical Center (Palo Alto, CA), Georgetown University School of Medicine (Washington, DC) and Providence Hospital (Washington, DC). We mailed 400 questionnaires directly to the individuals with a brief description of the study’s purpose and instructions to mail back completed questionnaires to the study coordinator (J.V.). There was no active follow-up of initial non-respondents. Survey
instrument
The questionnaire was conlidential and anonymous. The instrument was divided into three sections. Section 1 included sociodemographic information (e.g., level of training, specialty if any, years in practice). In section 2, the respondents answered a series of 4 multiple-choice questions about their attitudes regarding CPR for themselves. Section 3 consisted of seven items reflecting beliefs about outcome after attempted CPR in selected disease states. The entire questionnaire is reproduced in the Appendix. Data
analysis
We used chi-square analysis with subgroup differences among responses. limit of statistical significance.
Yates correction for continuity to assess We selected a P-value of 0.05 as the upper
RESULTS
Table 1 summarizes the response rate by respondent group. There were no signilicant differences in response rates and an overall return rate of 60%. No systematic differences were noted among different levels in each respondent subgroup. For that reason we coalesced respondent levels within each respondent grouping. There were no statistically significant differences in response rate by institution.
231
Table I.
Characteristics
of responders.
Group
Sent
Medical students House officers
150 l-15
95 77
63 62
Attending Nurses Total
75 50 400
3x 24 234
51 4x 60
physicians
*Chi-square
= 6.12. df = 3: Not stattstically
Response
Recetved
rate ‘%
significant
The results of preferences of medical personnel concerning place of resuscitation, code status, team leader and duration of resuscitation attempts, are presented in Table II. The majority of all respondents preferred a university hospital setting as the site for resuscitation, presumably reflecting their training and experience at such locations. There was an intriguing progression among physicians at different levels of training of preference for the university hospital setting. Greater numbers of the highly trained individuals preferred the university hospitals. The percentage of attending physicians with this preference approached that of the nurse respondents. In their comments, some nurses cited the lack of around-the-clock physician coverage in some private hospitals, while others felt that university and county hospitals have more experience with these situations. Less than half the respondents selected a second year medical or anesthesia resident as the optimal resuscitation team leader. Several medical students expressed fear of iatrogenic complications if the code were handled by housestaff or nurses.
Table II.
housestaff; anesthesia
Percentage (‘%I)of responses concerning resuscitation attempts. (MS) medical students: (HS) (AP) attending physicians; (RN) registered nurses: (Med. Res.) medical resident: (Anes. Res.) resident; (NS) not statistically significant.
Question
MS n = 95
Pluw qf rcwscituiion. University hospital
AP n = 38 (‘%I)
RN II = 24 (‘> = 3.S67 NS x12 = 10.8X4 P < 0.005 $7 = 18.498 P -< 0.001 x1, = 4.883 NS $9 = 29.138 P -< 0.001
of freedom
In contrast, most housestaff and attending physicians chose a cardiology fellow, while many nurses favored their critical care nurse counterparts. None of these differences were statistically significant. The groups displayed differences among their proclaimed personal code status. The vast majority of housestaff and attending physicians deemed themselves a full code, while approximately half of the medical student and nurse respondents indicated a preference for less than the most aggressive response for themselves. Attending physicians were most definitive about terminating resuscitative attempts if these were not successful within the first 10 min. The other respondent groups most consistently opted to continue at least an additional 15 min before stopping. Table III displays responses for individual pre-existing conditions which might influence code status. (The nurses’ data are not included because several categorical cells contain fewer than five subjects, making the use of chi-square inappropriate). None of the nurses selected a resuscitation attempt if they had pre-existing metastatic malignancy or the acquired immunodeticiency syndrome (AIDS). There were few differences between housestaff and attending physicians, presumably representing relative unanimity after a certain amount of clinical experience. In contrast, medical students opted for resuscitation even in the face of AIDS, metastatic cancer and severe chronic obstructive pulmonary disease (COPD). Medical students also elected resuscitation with Alzheimer’s dementia 35% of the time. in contrast with only 4% of housestaff and 3% of attending physicians. None of the nurses would have resuscitation efforts initiated under these circumstances. DISCUSSION
It is well established
that the mentally
competent
patient
has the right to decide
233
for or against life support interventions such as CPR. However, life support issues are not universally discussed with the patient [6]. For that reason, some authors have called for patients to increase active involvement in decision-making with their physicians about their medical care [7]. Previous reports have demonstrated that neither nurses nor physicians necessarily systematically understand their patients’ resuscitation preferences [S]. In the particular case of medical personnel, their frequent exposure to CPR situations may influence their attitudes toward the practice. Medical personnel’s perceptions of patients’ quality of life may also be affected by selective exposure. Farber et al. demonstrated the significant impact that patients’ biomedical, mental status and psychosocial factors have on the decision to initiate CPR by both internal medicine residents and registered nurses [9]. If the patient had a disease with a poor prognosis (i.e. metastatic cancer), CPR was often withheld. Vincent has described physicians’ attitudes towards ethical problems in the intensive care units (euthanasia, iatrogenesis, withdrawal of life support) [lo]. He found that there are several factors which may affect ethical decision making such as the age of the respondent, sex, religious background, primary specialty, intensive care experience and role in the intensive care unit. Our survey extend these efforts by sampling both non-physicians (nurses) and physicians at three levels of training. However, our samples are disparate and heterogeneous, with cardiac arrest exposure and experience varying from individual to individual. We sought to determine health professionals’ beliefs and attitudes regarding CPR for themselves. We anticipated that the expectations of trainees would be less realistic than those with greater experience. This is reflected in the opinions regarding the length of continuing resuscitation efforts. The attending physicians’ responses reflected a significantly greater inclination toward early termination of resuscitation efforts. It is intriguing, however, to note that significantly fewer of the students considered themselves to have full code status. Nonetheless, in responses to the inquiry regarding institution of CPR (which presumably reflect the survival rate of an underlying process) medical students displayed substantially more optimism regarding resuscitation in conjunction with COPD, AIDS, metastatic cancer and end-stage renal disease (ESRD) than did physicians with more extensive experience. Death is personal. Medical personnel can be expected to have very strong points of view concerning resuscitation. It is unclear how personal views such as those reflected in these responses are likely to influence the advice these health professionals are likely to give to patients or how treatment of critically ill patients is affected, if at all. CONCLUSIONS
Our survey responses among nurses, medical students and physicians reflect attitudes regarding CPR. Most health care professionals preferred resuscitation in a university hospital setting. A greater proportion of medical students and nurses identified themselves as having less than full code status. Attending physicians opted for a shorter resuscitation effort than did house staff or medical students, but a greater number opted for resuscitation in the face of AIDS, COPD, metastatic cancer and ESRD.
234
ACKNOWLEDGMENTS
The authors wish to thank all medical students, house officers, cians and registered nurses that participated in this study.
attending
physi-
REFERENCES Resuscitation in the elderly: A blessing or a curse? Ann. Intern. Med.. I I I (1989)193-S. M.H. Weil and E.C. Rackow. Cardiopulmonary resuscitation: A historical revrew. Acute Care. 12 (1986) 63-94. P. Safar. History of cardiopulmonary resuscitation, Acute Care, I? (1986) 61-2. D.J. Murphy. A.M. Murray and B.E. Robinson et al.. Outcome of cardiopulmonary resuscitation rn the elderly. Ann. Intern. Med., I I I (1989) 199-205. L.B. Becker. M.P. Ostrander, J. Barrett and C.T. Kondos. CPR Chicago. Outcome of CPR in a large metropolitan area - Where are the survivors?. Ann. Emerg. Med.. 20 (1991) 355-61. K. Asplund and M. Britton. Do-not-resuscitate orders in Swedish medical wards. J. Intern. Med., 228 ( 1990) 139-45. T.E. Hughes and L.N. Larson, Patient involvement in health cart. A procedural justice view-point. Med. Care. 29 (1991) 297-303.
I
P.J. Podrid,
2 S. Thangam. 3 4 5 6 7 8
R.F. Uhlmann. R.A. Pearlman and K.C. Cain, Understanding of elderly patrents‘ rcsuscrtatron preferences by physicians and nurses. West. J. Med., I50 (1989) 750-7. N.J. Farber, J.L. Weiner and E.G. Boyer et al.. Cardiopulmonary resuscitation. Values and decisions - A comparison of health care professionals. Med. Care. 23 (1985) 1391-X. J.L. Vincent, European attitudes towards ethical problems in intensive care medicine: results of an ethical questionnaire. Intensive Care Med., I6 (1990) 256-64.
9 IO
APPENDIX D.N.R.
QUESTIONNAIRE
We would
like
to know
and what
would
happen
- Please, Wed
circle
Resident
a)
are your
if YOU were
year
Student
Other
what
and experience
about
the
'Do not
reaucita+s'
orders
resuscitated.
of training:
1, 2, 3. 4
PGY
Specialty:
1, 2, 3, 4, 6
I
Please,
if you
l-3
b)
g) Wore
are
than
a" attending
c) 7-10
4-6
d)
20.
to have
a cardiac
to have
your
like
a) University b) Private
of
ar
14-17
faculty,
indicate
years
in practice:
f) 18-20
arrest
resuscitation
in the middle effort8
of the
eight.
at which
of the
following
?I
hospital
ho-pita1
Inner-city
2. noet
e)
Specialty:
1. If VXI WBZB you
phyeician
lo-13
would
c)
feelings
to be
or County
the
current
the patient
at the
a) 2nd year
medical
hospital
training
time,
which
reeLdent.
programa of the
allow
following
a 2nd year would
you
resident like
to
to -r"" 'run your
the code'. code'
?I
If You
=e
235
APPENDIX
(continued)
b)
year
anesthenia
c) Attending
physician
2nd
d) Cardiology
cart) R.N.
a) Definitely
full
b) Definitely
no code
c) Full
I have
4.
If the
minutes,
never
support
thought
attempt8 how
long
status':
code
pharmacologic
d)
ICU)
(let year)
your presmnt'code
is
what
(not
Fellow
e) Critical
3.
resident
but
about
it
no
of resuecitation would
you
like
Intubation/Chest
compreseions.
('undecided').
performed
the
'Code
on yo" were
team.
not
to continue
succeesful
within
the
firet
10
?r
a) stop. b)
15 minutes
C)
20 minutes
d)
30 minutes
e) 60 minutea
- If you were event
of
(~leasa
to have
any of the
a cardiorespiratory circle
5)
More
6)
Knd-stage
than
7)
A.I.D.S.
S)
netastatic
9)
SepELS
10) Alzhsimer’a 11) Severs
each
old
disease
cancer
dementia
C.O.P.D.
conditions,
arreet.7:
an.we~r)
65 years renal
following
Ye8
No
Yes
No
Yes
No
Ye8
No
Ye8
No
Yes
No
Yes
No
would
you like
to be renuecitated
in M
22 (1991)
Elsevier Scientific
229
229-235
Publishers
Ireland
Ltd
Resuscitation attitudes among medical personnel: How much do we really want to be done? Joseph
“Department
of
Emergency sity Medical
Varon”,
Medicine,
George L. Sternbachb, Arthur H. Combsd
SIOZC,
Medicine
Service,
Center,
Stanford, Care Area,
Associate
Providence
resuscitation
Hospital.
July 28th.
Professor
of Surgery,
of‘Medicine, Depurrmenl
Professor
CA 94305 und “Associate
(Received
Cardiopulmonary
hClinicul
“Associate
Peter Rudd’ and
Clinical
WashinKron.
1991: Accepted
(CPR) is attempted
Profkwr
of Medicine
DC 20017
August
Departmml
of Medicine. i U.S. A.
(!f Surgery.
Stanjbrd Director.
UniverCritiurl
I
19th. 1991)
every day. Whereas
medical professionals
and per-
sonnel perform these resuscitation attempts. no previous studies have reported the attitudes of medical personnel towards resuscitation for themselves. We have attempted to assess the prevalent attitudes among various physicians at various levels in training and nurses. An eleven item questionnaire was sent to medical students, house officers. attending physicians and registered nurses at university medical centers. Each questionnaire consisted of respondent’s sociodemographic information. their attitudes about CPR for themselves and their beliefs about outcome after CPR with particular disease states. The results were analyzed using chi-square analysis. Four hundred questionnaires were mailed and 240 were returned (6@% response rate). All groups favored resuscitation in a university hospital over other sites (P < 0.05). More nurses requested to be ‘no code’ compared with other professionals (P < 0.005). Attending physicians requested that CPR attempts be terminated after less time than any other group (P < 0.005). Medical students requested resuscitation significantly more than any other group in the presence of terminal conditions such as metastatic cancer, acquired immunodeficiency syndrome and severe chrome obstructive pulmonary disease (P < 0.005). Medical personnel’s beliefs about CPR may be influenced by their experiences with particular patients and events. As trainees acquire more experience they appear less inclined to desire resuscitation efforts for themselves. Attitudes
- Cardiopulmonary
resuscitation
- Code status
- Housestaff
- Resuscitation
INTRODUCTION
Sudden cardiac death accounts for 400 000-600 000 deaths each year in the United States [I]. Attempting resuscitation from cardiopulmonary arrest is an everyday event. Modern external cardiopulmonary resuscitation (CPR) began in the 1950’s with documentation of how basic life support could succeed [2]. Its use expanded throughout American hospitals in the 1960’s and early 1970’s [3]. Success rates for inpatient and outpatient CPR (defined as those patients leaving the hospital Address all correspondence
Baylor College of Medicine.
und reprint
requests
One Baylor
to: Joseph
Plaza.
0300-9572/911$03.50 0 199 I Elsevier Scientific Printed and Published in Ireland
Houston, Publishers
Varon. Pulmonary and Critical TX 77030. U.S.A. Ireland
Ltd
Care Section.
230
alive) have varied from O-30% [4,5]. Enthusiasm based on results in sudden cardiac death have led to the development of intensive campaigns to train and recertify both lay persons and medical personnel in basic and advanced cardiac life support. To determine the attitudes of medical personnel towards resuscitation for themselves, we conducted a survey of medical students, residents, attending physicians and nurses. We were specifically interested in their desires and expectations of CPR should they sustain a cardiac arrest and in their prediction of the effectiveness of CPR in selected patient populations. MATERIALS
AND
METHODS
We developed and distributed a two page, eleven item, questionnaire students, housestaff, attending physicians and nurses over (February-August, 1990). Survey
to medical 7 months
administration
We obtained the names and home addresses of medical students (all levels), house officers (internal medicine, surgery, pulmonary, oncology), attending physicians (general internal medicine and medical subspecialties) and general medicine ward nurses at Stanford University School of Medicine (Stanford, CA), Palo Alto VA Medical Center (Palo Alto, CA), Georgetown University School of Medicine (Washington, DC) and Providence Hospital (Washington, DC). We mailed 400 questionnaires directly to the individuals with a brief description of the study’s purpose and instructions to mail back completed questionnaires to the study coordinator (J.V.). There was no active follow-up of initial non-respondents. Survey
instrument
The questionnaire was conlidential and anonymous. The instrument was divided into three sections. Section 1 included sociodemographic information (e.g., level of training, specialty if any, years in practice). In section 2, the respondents answered a series of 4 multiple-choice questions about their attitudes regarding CPR for themselves. Section 3 consisted of seven items reflecting beliefs about outcome after attempted CPR in selected disease states. The entire questionnaire is reproduced in the Appendix. Data
analysis
We used chi-square analysis with subgroup differences among responses. limit of statistical significance.
Yates correction for continuity to assess We selected a P-value of 0.05 as the upper
RESULTS
Table 1 summarizes the response rate by respondent group. There were no signilicant differences in response rates and an overall return rate of 60%. No systematic differences were noted among different levels in each respondent subgroup. For that reason we coalesced respondent levels within each respondent grouping. There were no statistically significant differences in response rate by institution.
231
Table I.
Characteristics
of responders.
Group
Sent
Medical students House officers
150 l-15
95 77
63 62
Attending Nurses Total
75 50 400
3x 24 234
51 4x 60
physicians
*Chi-square
= 6.12. df = 3: Not stattstically
Response
Recetved
rate ‘%
significant
The results of preferences of medical personnel concerning place of resuscitation, code status, team leader and duration of resuscitation attempts, are presented in Table II. The majority of all respondents preferred a university hospital setting as the site for resuscitation, presumably reflecting their training and experience at such locations. There was an intriguing progression among physicians at different levels of training of preference for the university hospital setting. Greater numbers of the highly trained individuals preferred the university hospitals. The percentage of attending physicians with this preference approached that of the nurse respondents. In their comments, some nurses cited the lack of around-the-clock physician coverage in some private hospitals, while others felt that university and county hospitals have more experience with these situations. Less than half the respondents selected a second year medical or anesthesia resident as the optimal resuscitation team leader. Several medical students expressed fear of iatrogenic complications if the code were handled by housestaff or nurses.
Table II.
housestaff; anesthesia
Percentage (‘%I)of responses concerning resuscitation attempts. (MS) medical students: (HS) (AP) attending physicians; (RN) registered nurses: (Med. Res.) medical resident: (Anes. Res.) resident; (NS) not statistically significant.
Question
MS n = 95
Pluw qf rcwscituiion. University hospital
AP n = 38 (‘%I)
RN II = 24 (‘> = 3.S67 NS x12 = 10.8X4 P < 0.005 $7 = 18.498 P -< 0.001 x1, = 4.883 NS $9 = 29.138 P -< 0.001
of freedom
In contrast, most housestaff and attending physicians chose a cardiology fellow, while many nurses favored their critical care nurse counterparts. None of these differences were statistically significant. The groups displayed differences among their proclaimed personal code status. The vast majority of housestaff and attending physicians deemed themselves a full code, while approximately half of the medical student and nurse respondents indicated a preference for less than the most aggressive response for themselves. Attending physicians were most definitive about terminating resuscitative attempts if these were not successful within the first 10 min. The other respondent groups most consistently opted to continue at least an additional 15 min before stopping. Table III displays responses for individual pre-existing conditions which might influence code status. (The nurses’ data are not included because several categorical cells contain fewer than five subjects, making the use of chi-square inappropriate). None of the nurses selected a resuscitation attempt if they had pre-existing metastatic malignancy or the acquired immunodeticiency syndrome (AIDS). There were few differences between housestaff and attending physicians, presumably representing relative unanimity after a certain amount of clinical experience. In contrast, medical students opted for resuscitation even in the face of AIDS, metastatic cancer and severe chronic obstructive pulmonary disease (COPD). Medical students also elected resuscitation with Alzheimer’s dementia 35% of the time. in contrast with only 4% of housestaff and 3% of attending physicians. None of the nurses would have resuscitation efforts initiated under these circumstances. DISCUSSION
It is well established
that the mentally
competent
patient
has the right to decide
233
for or against life support interventions such as CPR. However, life support issues are not universally discussed with the patient [6]. For that reason, some authors have called for patients to increase active involvement in decision-making with their physicians about their medical care [7]. Previous reports have demonstrated that neither nurses nor physicians necessarily systematically understand their patients’ resuscitation preferences [S]. In the particular case of medical personnel, their frequent exposure to CPR situations may influence their attitudes toward the practice. Medical personnel’s perceptions of patients’ quality of life may also be affected by selective exposure. Farber et al. demonstrated the significant impact that patients’ biomedical, mental status and psychosocial factors have on the decision to initiate CPR by both internal medicine residents and registered nurses [9]. If the patient had a disease with a poor prognosis (i.e. metastatic cancer), CPR was often withheld. Vincent has described physicians’ attitudes towards ethical problems in the intensive care units (euthanasia, iatrogenesis, withdrawal of life support) [lo]. He found that there are several factors which may affect ethical decision making such as the age of the respondent, sex, religious background, primary specialty, intensive care experience and role in the intensive care unit. Our survey extend these efforts by sampling both non-physicians (nurses) and physicians at three levels of training. However, our samples are disparate and heterogeneous, with cardiac arrest exposure and experience varying from individual to individual. We sought to determine health professionals’ beliefs and attitudes regarding CPR for themselves. We anticipated that the expectations of trainees would be less realistic than those with greater experience. This is reflected in the opinions regarding the length of continuing resuscitation efforts. The attending physicians’ responses reflected a significantly greater inclination toward early termination of resuscitation efforts. It is intriguing, however, to note that significantly fewer of the students considered themselves to have full code status. Nonetheless, in responses to the inquiry regarding institution of CPR (which presumably reflect the survival rate of an underlying process) medical students displayed substantially more optimism regarding resuscitation in conjunction with COPD, AIDS, metastatic cancer and end-stage renal disease (ESRD) than did physicians with more extensive experience. Death is personal. Medical personnel can be expected to have very strong points of view concerning resuscitation. It is unclear how personal views such as those reflected in these responses are likely to influence the advice these health professionals are likely to give to patients or how treatment of critically ill patients is affected, if at all. CONCLUSIONS
Our survey responses among nurses, medical students and physicians reflect attitudes regarding CPR. Most health care professionals preferred resuscitation in a university hospital setting. A greater proportion of medical students and nurses identified themselves as having less than full code status. Attending physicians opted for a shorter resuscitation effort than did house staff or medical students, but a greater number opted for resuscitation in the face of AIDS, COPD, metastatic cancer and ESRD.
234
ACKNOWLEDGMENTS
The authors wish to thank all medical students, house officers, cians and registered nurses that participated in this study.
attending
physi-
REFERENCES Resuscitation in the elderly: A blessing or a curse? Ann. Intern. Med.. I I I (1989)193-S. M.H. Weil and E.C. Rackow. Cardiopulmonary resuscitation: A historical revrew. Acute Care. 12 (1986) 63-94. P. Safar. History of cardiopulmonary resuscitation, Acute Care, I? (1986) 61-2. D.J. Murphy. A.M. Murray and B.E. Robinson et al.. Outcome of cardiopulmonary resuscitation rn the elderly. Ann. Intern. Med., I I I (1989) 199-205. L.B. Becker. M.P. Ostrander, J. Barrett and C.T. Kondos. CPR Chicago. Outcome of CPR in a large metropolitan area - Where are the survivors?. Ann. Emerg. Med.. 20 (1991) 355-61. K. Asplund and M. Britton. Do-not-resuscitate orders in Swedish medical wards. J. Intern. Med., 228 ( 1990) 139-45. T.E. Hughes and L.N. Larson, Patient involvement in health cart. A procedural justice view-point. Med. Care. 29 (1991) 297-303.
I
P.J. Podrid,
2 S. Thangam. 3 4 5 6 7 8
R.F. Uhlmann. R.A. Pearlman and K.C. Cain, Understanding of elderly patrents‘ rcsuscrtatron preferences by physicians and nurses. West. J. Med., I50 (1989) 750-7. N.J. Farber, J.L. Weiner and E.G. Boyer et al.. Cardiopulmonary resuscitation. Values and decisions - A comparison of health care professionals. Med. Care. 23 (1985) 1391-X. J.L. Vincent, European attitudes towards ethical problems in intensive care medicine: results of an ethical questionnaire. Intensive Care Med., I6 (1990) 256-64.
9 IO
APPENDIX D.N.R.
QUESTIONNAIRE
We would
like
to know
and what
would
happen
- Please, Wed
circle
Resident
a)
are your
if YOU were
year
Student
Other
what
and experience
about
the
'Do not
reaucita+s'
orders
resuscitated.
of training:
1, 2, 3. 4
PGY
Specialty:
1, 2, 3, 4, 6
I
Please,
if you
l-3
b)
g) Wore
are
than
a" attending
c) 7-10
4-6
d)
20.
to have
a cardiac
to have
your
like
a) University b) Private
of
ar
14-17
faculty,
indicate
years
in practice:
f) 18-20
arrest
resuscitation
in the middle effort8
of the
eight.
at which
of the
following
?I
hospital
ho-pita1
Inner-city
2. noet
e)
Specialty:
1. If VXI WBZB you
phyeician
lo-13
would
c)
feelings
to be
or County
the
current
the patient
at the
a) 2nd year
medical
hospital
training
time,
which
reeLdent.
programa of the
allow
following
a 2nd year would
you
resident like
to
to -r"" 'run your
the code'. code'
?I
If You
=e
235
APPENDIX
(continued)
b)
year
anesthenia
c) Attending
physician
2nd
d) Cardiology
cart) R.N.
a) Definitely
full
b) Definitely
no code
c) Full
I have
4.
If the
minutes,
never
support
thought
attempt8 how
long
status':
code
pharmacologic
d)
ICU)
(let year)
your presmnt'code
is
what
(not
Fellow
e) Critical
3.
resident
but
about
it
no
of resuecitation would
you
like
Intubation/Chest
compreseions.
('undecided').
performed
the
'Code
on yo" were
team.
not
to continue
succeesful
within
the
firet
10
?r
a) stop. b)
15 minutes
C)
20 minutes
d)
30 minutes
e) 60 minutea
- If you were event
of
(~leasa
to have
any of the
a cardiorespiratory circle
5)
More
6)
Knd-stage
than
7)
A.I.D.S.
S)
netastatic
9)
SepELS
10) Alzhsimer’a 11) Severs
each
old
disease
cancer
dementia
C.O.P.D.
conditions,
arreet.7:
an.we~r)
65 years renal
following
Ye8
No
Yes
No
Yes
No
Ye8
No
Ye8
No
Yes
No
Yes
No
would
you like
to be renuecitated
in M
