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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62:395-400 (2007)
© 2007 The Gerontological Society of America

Prevalence of Patients With Do-Not-Resuscitate Status on Acute Geriatric Wards in Flanders, Belgium

Cindy De Gendt, Johan Bilsen, Nele Van Den Noortgate, Margareta Lambert, Robert Vander Stichele and Luc Deliens

1 End-of-Life Care Research Group, Vrije Universiteit Brussel, Belgium.
2 Centre for Environmental Philosophy and Bioethics, Ghent University, Belgium.
3 Department of Geriatrics, Ghent University Hospital, Belgium.
4 Department of Geriatrics, Academic Hospital Vrije Universiteit Brussel, Belgium.
5 Heymans Institute of Pharmacology, Ghent University, Belgium.
6 Department of Public and Occupational Health, EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands.

Address correspondence to Cindy De Gendt, MSc, End-of-Life Care Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium. E-mail: cindy.de.gendt{at}vub.ac.be


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Elderly hospitalized patients have low survival rates after cardiopulmonary resuscitation, especially in the long term. This study aims to investigate the prevalence of patients with do-not-resuscitate (DNR) status on acute geriatric wards and the characteristics of the preceding decision-making process.

Methods. On all 94 geriatric wards in Flanders, Belgium (2002), the geriatrician who performed the bulk of clinical work was asked to fill in a retrospective structured mail questionnaire.

Results. The response rate was 72.3%. A DNR status was attributed to 20.3% of patients. A significant higher prevalence of patients with DNR status was found on wards with a geriatrician who had been active in patient care for 15 years or less and on wards with a DNR policy. Mostly, DNR status was attributed when the patient's condition declined (34.0%) or became critical (29.0%). Geriatricians consulted at least one person in 81.0% of the cases: (head) nurses in 72.2%, next of kin in 61.9%, the patient's general practitioner in 22.6%, and the patient him- or herself in 15.7%. Reasons stated to make a DNR decision were the prognosis (68.1%) and the physical condition of the patient (62.2%). Age was mentioned in only 21.1% of the cases, always in combination with other reasons.

Conclusions. One fifth of patients on acute geriatric wards in Flanders have DNR status. The decision to attribute DNR status is most often made late in the course of the disease. (Head) nurses and the patient's next of kin are often consulted, the patient and his or her general practitioner rarely.

BECAUSE of advances in medical knowledge and technology, many people nowadays live to be very old, however, often with chronic and degenerative diseases which may result in poor quality of life (1,2). Many old and very old elderly persons, especially those admitted to acute geriatric wards, have serious underlying comorbidity decreasing their chance of survival after cardiopulmonary resuscitation (CPR), especially in the long term (2–6).

Although do-not-resuscitate (DNR) decisions are now common practice (7), no studies have been conducted to establish the prevalence of DNR status in elderly patients hospitalized on acute geriatric wards on a nationwide scale. The DNR status of patients on a single geriatric ward was studied in The Netherlands (8,9) and the United States (10). In other studies, this prevalence was studied in intensive care units or general wards (11,12).

This study aims to investigate the prevalence of patients with DNR status and the characteristics of the preceding decision-making process in the setting of acute geriatric wards in Flanders (the Dutch-speaking part of Belgium).

In Flanders, acute geriatric wards were installed since 1984 for specialized acute geriatric care, restricted in length of hospital stay, and with a multidisciplinary approach (13). In 2002, the total number of acute geriatric beds in Flanders was 4072, with a yearly occupancy rate of 85.9%, serving 41,138 hospitalizations, with an average length of stay of 31 days. In 86% of the wards, a DNR policy was available (14).


   METHODS
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 Methods
Results
 Discussion
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Design
This study was conducted in spring 2002 in Flanders, the Dutch-speaking part of Belgium, where about 60% of the Belgian population lives. In this area, 64 acute hospitals had at least one acute geriatric ward. Due to administrative mergers, some hospitals had an acute geriatric ward at different hospital sites (39 hospitals had 1 site with a geriatric ward, 21 had 2 sites, 3 had 3 sites, and 1 had 4 sites). All 94 hospital sites were included in this study. The Ministry of Health provided a list of these sites which included addresses and institutional characteristics such as ownership (private or public), type of hospital (general or university), total bed capacity of the hospital site and the geriatric ward, and availability of an intensive care unit and a palliative support team.

A structured mail questionnaire was sent to the geriatrician (a specialist in internal medicine, with a supplementary 1-year specialization in geriatric medicine), who performed the bulk of clinical work on the geriatric ward (N = 94). To assure an appropriate response rate, the Total Design Method was used (15). One week before the first mailing of the questionnaire in April 2002, a recommendation letter from the Belgian Society of Gerontology and Geriatrics was sent to the geriatricians. A follow-up card was sent to all 1 week after the first mailing. Two weeks later, a follow-up letter was mailed with a copy of the questionnaire to the nonresponders.

Questionnaires
The first questions of the questionnaire inquire after the existence of a DNR policy, inspired by an existing questionnaire regarding this topic in The Netherlands (16). The two following questions asked geriatricians for the number of patients currently registered on the geriatric ward under their supervision, and for the number of these patients with DNR status at the time that the questionnaire was completed. The next five questions, based on international literature (17–19), investigated the characteristics of the preceding decision-making process, leading to the attribution of DNR status. Geriatricians were asked to register the moment of decision-making, who was consulted, whether this decision took place during the weekly team meeting or the daily ward visits, whether the decision was documented in the patient's file, and the main reasons for the decision (maximum three). Finally, gender, number of years active in patient care, and attendance at an intensive course on palliative care were recorded for all geriatricians.

The questionnaire was thoroughly reviewed by two geriatricians and then pilot-tested by a group of 14 geriatricians. This resulted in minor adaptations to the text to solve ambiguity and to improve understanding. In the questionnaire, a patient with DNR status was defined as "a patient for whom an anticipatory decision not to start resuscitation in case of a cardiac and/or respiratory arrest was made" (17).

Statistical Analysis
Hospital and ward characteristics of the response sample were compared with those of the nonresponse sample using Fisher's Exact test. The prevalence of patients with DNR status on geriatric wards was calculated as the proportion of the total number of patients with DNR status divided by the total number of treated patients at the moment of completing the questionnaire. Descriptive results were presented in frequency tables and cross-tabs, and differences in distribution and means were calculated by using, respectively, Fisher's Exact test and the independent samples t test. Multiple linear regression analysis was used to further investigate the significant relationships between characteristics of the geriatrician, the hospital site, and the geriatric ward, with the percentage of patients with a DNR status per geriatrician. For all these analyses, the statistical package SPSS 12.0 (SPSS Inc., Chicago, IL) was used. A p value less than.05 was considered statistically significant.


   RESULTS
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 Methods
 Results
Discussion
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Description of Response and Nonresponse Sample
From the 94 hospital sites with an acute geriatric ward, 68 geriatricians returned their completed questionnaire (72.3% response rate). Response and nonresponse samples were compared for characteristics of the hospital site and the geriatric ward (Table 1). Except for bed capacity of the geriatric ward (p =.013), no significant differences were found. The observed underrepresentation of the smallest geriatric wards (24 beds) in the response sample and the results were weighted for bed capacity of the geriatric ward of all hospital sites with an acute geriatric ward in Flanders (2002).


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  		Table 1. Institutional Characteristics of Response and Nonresponse Sample.

 
Prevalence and Characteristics of DNR Decisions
The 68 responding geriatricians reported 393 patients with DNR status of a total of 1925 treated patients on acute geriatric wards, which represents 20.3% (data not shown in table). For each responding geriatrician, the proportion of patients with DNR status was calculated. The average percentage of this proportion was 19.6% (ranging from 0% to 62%) (Table 2). Eight geriatricians had no patients with DNR status at the time of this study, but they had all made (at least once) a DNR decision in the past. Female geriatricians had more patients with DNR status (25.9%) than did their male colleagues (15.6%, p =.022). The number of years that geriatricians were active in patient care was significantly related with the proportion of patients with a DNR status. Geriatricians who had been active in patient care for 15 years or less had more patients with DNR status (27.6%) than did those who had been active in patient care for 16–25 years (12.4%, p =.001) and those who had been active for more than 25 years (15.7%, p =.024). About half of the geriatricians had attended an intensive course on palliative care, but there was no significant relationship with the proportion of patients with DNR status.


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  		Table 2. Average Proportion of Patients with Do-Not-Resuscitate (DNR) Status per Geriatrician According to Characteristics of the Geriatrician, the Hospital Site, and the Geriatric Ward (N = 68)*.

 
On acute geriatric wards where a DNR policy was available, the average proportion of patients with a DNR status was higher (23.1%) than on wards without such a policy (5.8%, p =.000). No other characteristics of the hospital site and the geriatric ward were significantly associated with the proportion of patients with a DNR status per geriatrician.

Multiple linear regression analysis revealed that only the number of years active in patient care (ß = –.298, p =.004) and the existence of a DNR policy (ß = –.361, p =.000) (but not gender of the geriatrician) were significantly related with the proportion of patients with DNR status.

The DNR Decision-Making Process
The moment at which the last DNR decision was made was in 28.3% of patients before or at the time of admission, in 8.7% after diagnosis, in 34.0% when the patient's situation declined, and in 29.0% when the condition became critical (Table 3)<--?1-->.


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  		Table 3. Characteristics of the Decision-Making Process, Preceding the Last Do-Not-Resuscitate (DNR) Decision (N = 68).

 
Geriatricians previously consulted at least one other person in 81.0% of the cases. In 72.2% the head nurse or another nurse of the geriatric ward was involved, in 61.9% the patient's next of kin, and in 36.0% a second specialist of the hospital site. The general practitioner of the patient was consulted in 22.6% of the cases and the patient him- or herself in 15.7%. In 69.2% of the cases, discussion took place during the weekly team meeting (38.5%) and/or during the geriatrician's daily ward visits (44.6%). The last DNR decision was documented in the patient's file by 93.7% of the geriatricians.

The most reported reason for the last DNR decision was prognosis of the disease (68.1%), followed by the physical condition of the patient (62.5%), the mental condition of the patient (45.6%), the expected quality of life after CPR (42.8%), and the probability of success of CPR (42.3%). The geriatricians reported in 21.1% of the cases that the age of the patient was a reason to make the last DNR decision, always in combination with (at least) the physical and/or mental condition of the patient. One geriatrician considered economic aspects for his last DNR decision.

All characteristics of the DNR decision-making process were tested (Fisher's Exact test; not shown in table) for characteristics of the geriatrician, the hospital site, and the geriatric ward. Geriatricians who had been active in patient care for 15 years or less more often consulted general practitioners (43.3% vs 10.5%, p =.025) as well as the patient (33.3% vs 0.0%, p =.004) compared to those who had been active for more than 25 years. No other significant differences were found. There was also no significant relationship between consultation with different persons and the moment when the last DNR decision was made.


   DISCUSSION
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 Methods
 Results
 Discussion
References
 
To our knowledge, this study is the first to investigate the prevalence of patients with DNR status and the characteristics of the decision-making process preceding the attribution of such status on acute geriatric wards in a nationwide catchment area (Flanders), rather than on individual wards. No significant differences were found between response and nonresponse sample, except for bed capacity of the geriatric ward (small wards slightly underrepresented). Results were weighted for this difference. Hence, the study sample can be considered to be representative for the whole of Flanders.

There are some limitations to this study. First, because data on patients' characteristics were not obtained, their relationship with the characteristics of the decision-making process could not be investigated in this study. Second, situational circumstances might have had an influence on the point prevalence of DNR decisions.

The results of this study reveal that 1 of 5 patients hospitalized on acute geriatric wards in Flanders have DNR status. DNR decisions are most frequently made by younger geriatricians and on wards with a DNR policy, and are mostly made late in the course of the disease. The main reasons for such decisions are disease-related. Patients and their general practitioner are rarely consulted in the decision-making process.

The prevalence of DNR decisions on acute geriatric wards in Flanders is slightly higher than most international data regarding DNR decisions in hospitals or on specific wards (11,17,20–23), but these all concerned other patient populations. When comparing with results obtained in geriatric wards, the prevalence of patients with DNR status in Flanders is slightly higher than in the United States (16%) (10) but substantially lower than in The Netherlands (55% and 79%) (8,9). However, in Flanders there are also some wards where more than 50% of the patients had DNR status.

The finding that the proportion of patients with DNR status is higher among geriatricians who are younger (18) or who work on a ward where a DNR policy is available (24) is supported in international literature. The fact that younger geriatricians, who graduated more recently, have more patients with a DNR status than do older geriatricians might be the result of a generational effect (different attitudes or value patterns). Efforts to integrate end-of-life care in the basic education program (18) of the most recently graduated physicians might be another explanation, although less plausible because additional courses on palliative care seem to have no influence. Implementation of a DNR policy seems to stimulate geriatricians to reflect on attribution of a DNR status to patients when appropriate.

As confirmed by international literature (11,17,18,25,26), DNR decisions are mostly made late in the course of the disease and the most important reasons for such decisions are disease-related. Age of the patient is only mentioned as a reason in combination with the underlying condition of the patient. Together with the finding that the prevalence of DNR decisions on acute geriatric wards in Flanders is only slightly higher than for nongeriatric patient populations, there is no evidence that age alone is used as rationale for DNR decisions. The contrary would be unethical (25).

On acute geriatric wards in Flanders, 4 of 5 DNR decisions are discussed with others. Nurses are most frequently consulted in decision-making, probably because they care for the patient on a daily basis and often have a confidential and close relationship with the patient and his or her next of kin (26). Almost all DNR decisions (93.7%) were shared with the nursing team via the patient's file, which minimizes inappropriate CPR (14,27).

The low patient participation in DNR decision-making could be the result of many different factors such as the clinical condition (e.g., incompetence) of the patient at the (late) time of the decision-making, a paternalistic way of treating elderly patients, or the reluctance of patients to discuss this matter and pass this decision on to their family. The Patients' Rights Act (28), which came into force after this study, intends to improve the level of patient involve-ment in medical decision-making. It is also surprising that the patients' general practitioners are not often consulted, although they usually have a longstanding relationship with their patients and a good knowledge of the patient's situation and social context (29). Recently graduated geriatricians seem to involve more often the patient and the general practitioner; this might be explained by the earlier mentioned generational effect. Of course, it could also be a sign of the increasing autonomity of the patients and their families.

Although teamwork is very important in geriatric medicine (30), discussion about attributing DNR status to a patient more often took place during the daily ward visits than during the weekly team meeting. Different explanations could be found. First, although consultation with different persons was not significantly related to the moment of decision-making, it is possible that the late phase of the patient's illness did not leave the opportunity to discuss DNR during the weekly team meeting. The daily ward visits of the geriatrician seem to be an alternative option in these cases. Second, anticipating end-of-life decisions was perhaps not possible due to unexpected deterioration of the patient's condition. Third, a physician's paternalistic views could obstruct the team from participating in decision-making.

Based on this study, different intervention strategies can be proposed to optimize DNR decision-making. First, DNR should be discussed with others in advance. Planning care in advance provides better opportunities to involve the still competent patient and his or her next of kin and professional caregivers, and to collect better information about the patient's wishes (11,31). Nurses or other professional caregivers should discuss this matter as much as possible at the time of admission, because geriatric patients can lose competency later on, when the disease progresses. General practitioners should be more involved in DNR decision-making, starting with information about the implemented DNR policy in general, and concerning individual patients when necessary. Second, the development and implementation of a clear and standardized DNR policy, accepted by all persons concerned and recognizing the important role of all professional caregivers (especially nurses), should be stimulated. Third, ongoing efforts should be made to change the knowledge, communication skills, and attitudes of professional health caregivers (physicians, nurses) (32). In addition, the general public should be made more familiar with this matter, for example, by health information programs. Finally, further research is needed for more in-depth information about the DNR decision-making process and on how this process could be optimized (e.g., format and content of DNR policies and education).


   Acknowledgments
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 Methods
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 Discussion
 References
 
This work was supported by a research grant from the Research Council of the Vrije Universiteit Brussel and by the Geriatric Departments of the Vrije Universiteit Brussel and the University of Ghent.

We thank Annemie Van Hofstraeten for participation in the study concept and design and for data collection. In addition, we thank Johan Vanoverloop for advice on statistical issues and Kate McDonald for linguistic advice.


   Footnotes
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Decision Editor: Darryl Wieland, PhD, MPH

Received January 11, 2006

Accepted May 22, 2006


   References
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