Patient participation and associated factors in the discussions on do-not-attempt-resuscitation and end-of-life disclosure: a retrospective chart review study.
BACKGROUND
Patient participation is a key foundation of advance care planning (ACP). However, a patient himself/herself may be left out from sensitive conversations such as end-of-life (EOL) care discussions. The objectives of this study were to investigate patients' participation rate in the discussion of Cardiopulmonary Resuscitation (CPR) / Do-Not-Attempt-Resuscitation (DNAR) order, and in the discussion that the patient is at his/her EOL stage (EOL disclosure), and to explore their associated factors.


METHODS
This is a retrospective chart review study. The participants were all the patients who were hospitalized and died in a university-affiliated teaching hospital (tertiary medical facility) in central Tokyo, Japan during the period from April 2018 to March 2019. The following patients were excluded: (1) cardiopulmonary arrest on arrival; (2) stillbirth; (3) under 18 years old at the time of death; and (4) refusal by their bereaved family. Presence or absence of CPR/DNAR discussion and EOL disclosure, patients' involvement in those discussions, and their associated factors were investigated.


RESULTS
CPR/DNAR discussions were observed in 336 out of the 358 patients (93.9%). However, 224 of these discussions were carried out without a patient (patient participation rate 33.3%). Male gender (odds ratio (OR) = 2.37 [95% confidence interval (CI) 1.32-4.25]), living alone (OR = 2.51 [1.34-4.71]), and 1 year or more from the date of diagnosis (OR = 1.78 [1.03-3.10]) were associated with higher patient's participation in CPR/DNAR discussions. The EOL disclosure was observed in 341 out of the 358 patients (95.3%). However, 170 of the discussions were carried out without the patient (patient participation rate 50.1%). Patients who died of cancer (OR = 2.41[1.45-4.03]) and patients without mental illness (OR=2.41 [1.11-5.25]) were more likely to participate in EOL disclosure.


CONCLUSIONS
In this clinical sample, only up to half of the patients participated in CPR/DNAR discussions and EOL disclosure. Female, living with family, a shorter period from the diagnosis, non-cancer, and mental illness presence are risk factors for lack of patients' participation in CPR/DNAR or EOL discussions. Further attempts to facilitate patients' participation, based on their preference, are warranted.
['Abe|Akiko|A|http://orcid.org/0000-0003-4984-0273', 'Kobayashi|Masato|M|', 'Kohno|Takashi|T|', 'Takeuchi|Mari|M|', 'Hashiguchi|Saori|S|', 'Mimura|Masaru|M|', 'Fujisawa|Daisuke|D|']
D032722:Advance Care Planning D000368:Aged D000369:Aged, 80 and over D002318:Cardiovascular Diseases D002561:Cerebrovascular Disorders D030881:Disclosure D005260:Female D006801:Humans D008107:Liver Diseases D008297:Male D001523:Mental Disorders D008875:Middle Aged D009369:Neoplasms D016017:Odds Ratio D010358:Patient Participation D012111:Residence Characteristics D012140:Respiratory Tract Diseases D016414:Resuscitation Orders D012737:Sex Factors D013727:Terminal Care D013997:Time Factors
Patient participation Advance care planning Cardiopulmonary resuscitation (CPR) Do-not-attempt-resuscitation (DNAR) orders End-of-life discussion