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The surrogate's experience in authorizing a do not resuscitate order

Published online by Cambridge University Press:  19 February 2008

Catherine M. Handy ,
Daniel P. Sulmasy ,
Cindy K. Merkel  and
Wayne A. Ury
Catherine M. Handy
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York
Daniel P. Sulmasy*
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York New York Medical College, Valhalla, New York
Cindy K. Merkel
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York
Wayne A. Ury
Affiliation:
St. Vincents Catholic Medical Centers, New York, New York New York Medical College, Valhalla, New York
*
Address correspondences and reprint requests to: Daniel P. Sulmasy, John J. Conley Department of Ethics, St. Vincent's Hospital Manhattan, 153 W. 11th St., New York, NY 10011. E-mail: daniel_sulmasy@nymc.edu
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Abstract

Objective:

Little is known about the subjective experience of surrogates who authorize do not resuscitate (DNR) orders. This experience seems especially acute in settings such as New York State, where patients and surrogates generally give written consent for DNR orders. The goal of this study is to investigate the subjective and emotional experience of surrogates who authorize DNR orders in this setting.

Methods:

A qualitative, phenomenological research design was used. Surrogates of patients on the medical service were approached no earlier than 1 day and no later than 7 days after authorizing a DNR order. The interview guide was open-ended and included general prompts. Interviews were taped and transcribed. Researchers then coded the transcripts and examined the data for clusters of themes. They then met to discuss and recode disagreements.

Results:

Saturation was met after 10 subjects were interviewed. The following major surrogate themes were found: (1) Signing a DNR order is a process, not an isolated act. (2) The presence or absence of good quality communication and psychological support from health care personnel are among the most important factors in this process. (3) The process of signing a DNR order can raise many negative emotions including guilt, ambivalence, and conflict. (4) Prior discussions, documents such as living wills, and consensus among family members make it easier to determine the patient's wishes and carry them out by signing the DNR. (5) The surrogates believed that signing a DNR order is a prerequisite to obtaining adequate opioid analgesia.

Significance of results:

The experience of authorizing a DNR order is a complex and emotional decision-making process. Evidence of the patient's prior wishes and support from health care personnel make the process easier. It is disconcerting that surrogates viewed DNR orders as a prerequisite to obtaining relief for a patient's pain or suffering.

Keywords

SurrogateCommunicationDo not resuscitate ordersEthicsEnd-of-life care
Type
Original Articles
Information
Palliative & Supportive Care , Volume 6 , Issue 1 , March 2008 , pp. 13 - 19
Copyright
Copyright © Cambridge University Press 2008

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