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\begin{document}

\title{APPLICABILITY OF THE CONCEPT OF `DO NOT ATTEMPT RESUSCITATION' IN THE
EMERGENCY DEPARTMENT}



\author[1]{Aslı Şener}%
\author[1]{pınar hanife kara}%
\author[1]{erden erol ünlüer}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 28, 2024}


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\selectlanguage{english}
\begin{abstract}
Introduction : The issue of Do Not Attempt Resuscitation (DNAR), which
is still being debated all over the world, is extremely complex and has
not yet been discussed extensively in our country. Our aim in this
study; to determine the place of DNAR in emergency services and the
applicability of DNAR concept. Materials and Methods: This study was
designed as a cross-sectional survey in Turkey. The questions were
designed to examine physicians' approaches to the concept of DNAR,
whether they apply this concept and why. Results: A total of 246
physicians were reached. Sixty-nine physicians (30\%) stated that they
used DNAR in practice and metastatic terminal stage malignancy patients
were found to be the most accepted DNAR group. There was a statistically
significant difference between physicians' anxiety about physical
violence. Discussion: In order to increase the quality of CPR, patients
should be well analyzed. The applicability of the concept of DNAR in our
country is not legally possible. However, this situation does not
prevent the emergence of patients who will not benefit from treatment in
the clinic. Conclusion: It is best to establish a committee on DNAR and
redefine the legal rules within certain norms.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

The purpose of resuscitation is saving life, better health, relieving
pain, decreasing cobormidities and respecting the patient's decisions,
rights and privacy (1). Additionally, regarding cardiopulmonary
resuscitation (CPR), the very important aim is to prevent death (2).
Although general rule being the urgent treatment for cardiac arrest,
there are several occasions where not performing CPR is more convenient.
In a study, it is shown that 54,9\% of patients would not benefit from
CPR (3). CPR should be performed to patients whom will benefit the most.
Inevitable failure should not be accepted.

Do Not Attempt Resuscitation (DNAR) means do not perform resuscitation.
However, in various centers Allow Natural Death (AND) replaces DNAR (1).
DNAR definition should be well understood. Some physicians understand
DNAR just not performing CPR whereas some advocate not providing any
medical support to the patient. Not providing any medical support to the
patient is not accepted; neither in our county nor in the whole world.
Real DNAR decision only suggests not performing CPR. Next step should be
determining the person making the DNAR decision. DNAR decision should be
taken when the patient is having a cardiac arrest and needing CPR. This
decision is too much important to be made by a single person. In our
country, at CPR performing, ending and resuscitating, usually health
givers are managing the relations between the families showing a
paternalist approach. This paternalist approach is seriously criticized
in developed countries and is slowly replaced with ethical attitudes
involving the patient and his/her relatives (2). CPR decision should be
made not just in arrest occasions but also regarding the underlying
disease and the patient's personal evaluation and current situation.
Another important issue is the variations in health givers' religious
beliefs, occupations, ethnic features, and social status (3). In order
to maintain a standard management, clinicians, medical ethic
specialists, forensic medicine specialists, lawyers, sociologists,
religion experts and representatives of all different culture groups
should be involved to make a concrete decision (4).

Since DNAR term is not legitimately accepted in our country so it is not
performed. However, this does not change the number of patients whom
will not benefit from CPR performance. The `slow codes' (showing
inefficient resuscitative efforts initiatively) occurring in such
occasions is not an appropriate method (1). This application is a moral
burden for the decision maker. It results in ethical bias among health
givers, misinterpretation and damages the saver-patient relationship
(1). Additionally, it also raises the CPR incidence of the country and
decreases the successful CPR rate (5). DNAR being fiercely debated among
the world and it is not generally discussed in our country, yet.

Our aim in this study is to evaluate the role of DNAR in emergency
theaters and to determine the practicability of DNAR term.

\textbf{MATERIALS AND METHODS}

Our study is a cross-sectional survey study. The survey questions are
prepared by the researchers and distributed to the participants via
e-mail. The participants are informed about the thesis study and data
are collected via e-mail. Questions are focused on the attitudes of
physicians for DNAR definition, application of DNAR and the reasons of
application. The identity information of participants is not collected
while constituting the survey forms. All the emergency specialists whom
have answered the survey are involved to the study. The study protocol
was approved by the local ethics committee.

\textbf{Statistical Analysis}

SPSS\selectlanguage{ngerman}\textsuperscript{®} (Statistical Package for Social Sciences) for
Windows 21.0 is used for statistical analysis of the data. Average and
standard variation for numeric variants; number and percentage for
categorical variants are given as definitive statistics. Chi Square and
Fisher's Exact test for intergroup comparisons for categorical data is
used. Since the distributions were not normal (Kolmogorov Smirnov
p\textless{}0,05) in numerical variations, intergroup comparisons are
done via Mann Whitney U for two groups, Kruskal Wallis H for more than 2
groups are used for statistical analysis. Results are accepted as
statistically significant if p\textless{}0,05 in 95\% confidence
interval.

\textbf{RESULTS}

Total of 246 emergency specialists and trainees were included to the
study. The average age of the group was 33,25+/- 5,09. The demographic
features of the participants are shown in Table 1.

Among participants, 69 (30\%) mentioned that they use DNAR in practice
and 65 (26,5\%) think that the DNAR decision should be made by the
physician. 78 participants (31,7\%) mention that they understand not
performing CPR as DNAR due to inefficiency principal. Metastatic
terminal stage malignancy patients are found the most DNAR patients
(n=187; 76,3\%). DNAR decision making compared among the titles of
physicians, emergency specialists are the most physicians making this
decision (p\textless{}0,05).

One hundred and fifty-one physicians (59,2\%) mentioned that they did
not receive DNAR request from the patients' relatives. When DNAR request
of the patient or his/her relatives rate compared with the medical
center, there is not a statistically significant difference among
groups. However this request is found the highest in private hospitals.
As the relationship between title of the physician and the DNAR request
rate compared, the academic titled physicians found to be the most
request taking group which is found statistically significant
(p\textless{}0,05). Only 12 physicians /11,4\%) officially recorded DNAR
request. 84 physicians (36,1\%) mentioned that DNAR application in
emergency theater will be safe if this procedure is confirmed by law.
This rate is found to be higher in female group (n=30; 51,7\%).

It is not statistically significant among groups whom share and do not
share their DNAR decision making with the relatives of the patients. The
most of the reservation of not sharing DNAR decision with patient's
relatives is found to be the legal uncertainty which is statistically
higher than other causes (p\textless{}0,05). When not sharing DNAR
decision with the relatives and the physician's working place compared,
physical violence is found to be statistically significant
(p\textless{}0,05). This ratio is found most in research and training
hospitals {[}70 (60,9\%){]} and least in private hospitals {[}2
(28,6\%){]}. When the titles of the physicians and not sharing DNAR
decision compared, the disturbance of physical violence is found least
in academic titled physicians {[}11 (31,4\%){]} and most in trainees
{[}26 (60,5\%){]} last then 2 years. The relationship between
reservation for not sharing DNAR decision with relatives and the working
years in emergency theater is analyzed and psychological, physical and
verbal violence and other causes did show a statistical significance
(p\textless{}0,05). Psychological, physical and verbal violence is
determined as a reservation among physician working less than 10 years
in the emergency service. Violence reservations rates in physicians
working in emergency theater more than ten years found lower compared to
other groups. Although a statistically significance for reservations due
to legal mistrust is not observed it is found lower in physicians
working more than 10 years in emergency service.

\textbf{DISCUSSION}

We have two main conclusions in our study. Especially DNAR being illegal
in our country constricts the entire steps towards its application.
Second, DNAR still stands a responsibility fully taken by the physicians
which they cannot explain in all terms.

AHA guidelines suggest that if not eligible, health givers should not be
forced to perform CPR (6). Patients and their relatives have the most
right to speak about DNAR decision in Switzerland. In Europe and in our
country, the paternalist approach, in which externalizes
patients/relatives, is still in use. Yang et al has showed that
physicians believe they are the only authority in DNAR decision (7).
Park et al suggest nurses should be involved in DNAR decision while
communicating with the health givers and patients/relatives (8). 30\% of
our participants mentioned that they are actively applying DNAR while
26\% think that the decision is physician's responsibility. This points
that only 4\% of the physicians think that patients/relatives should be
included in decision making. Most of the physicians who are not willing
to take full responsibility of self-made DNAR decision are still
performing CPR although they know the patient will not benefit from it.
Nevertheless, another study shows that inadequate knowledge about DNAR
keep physicians from this application (9). In the study of McIntosh et
al, patients', relatives' and physicians' awareness is been tried to
raise with simple efforts and they have made it (10). We did not make
query about DNAR education which is limitation of our study. As being a
traditional society with being most of its citizens belonging to Muslim
religion accompanied by low sociocultural level, we believe these
factors lack DNAR decision in our country. Religion is one of the most
significant aspect for DNAR decision-making process. Most of Muslims,
with the faith of God's healing power and hope, prefer CPR neglecting
the prognosis of the underlying disease (11). With this background and
DNAR term being currently illegal, it seems impossible to debate about
DNAR with relatives in our country. Initially, a well-organized study
should be maintained and then legal basis should be prepared.
Afterwards, the ideal way of language should be determined for community
norms to share DNAR with patients/relatives.

The most important determinants in DNAR decision are found to be
prognosis of the disease and expected life quality (12). The most DNAR
requests belong to malignant tumors, dementia, cerebrovascular disease
sequels (13). Compatible with literature, in our study, ``metastatic
terminal stage malignancy patients'', elder patients with multiple
comorbid diseases and patients with concrete evidence for irreversible
death patients were found to have tendency for DNAR. This result shows
that our physicians still accept CPR as a treatment and are aware of the
fact that it should not be performed to those that will not benefit from
it. Regardless of the underlying disease prognosis, if the patient
requests CPR, it should definitely been performed. Whoever decides to
limit or end life support to a patient, one should preserve the
principles of providing necessary health care and not initiate or end
unnecessary acts. Compatible with literature, the most important factor
influencing DNAR decision is found to be inexpediency principle. As the
experience of the physician decreases, DNAR acceptance increases.
Academic titled physicians might trust themselves more due to their
experience and knowledge or might be more cautious for malpractice
incidence. As the training experience decreases due to long hours of
work might diminish the physician's time and energy and might give up
more easily.

In the study of Bedell et al, it is shown that only in 19\% of patients
who had received CPR had discussed it with their physician, and in 33\%
the family was consulted (14). Similarly DNAR decision was shared with
77-86\% with the relatives; only 14-22\% was discussed with the patient
(15). Murphey et al showed in their study that 41\% of elders wanted CPR
performance. 22\% of the patients whose discharge or survival rates
determined as 10-17\% accepted CPR performance --after fully informed
about DNAR-. When discharge or survival rates dropped to 0-5\%, CPR
performance requirement decreased to 5\% (16). As the community, our
country is not prepared for DNAR condition. Our DNAR rate is found
40,1\%. The cause of this might be related to cultural background of the
population or beliefs against DNAR. However, if the necessary
acknowledgement is ensured precisely, we believe this ratio will raise
in our country. This seems possible only with obligatory legal
regulations. In a study a special training is needed for DNAR
elucidating because DNAR can be easilu misunderstood by the
patient/relatives and usually understood as euthanasia (9). DNAR request
ratios are found to be higher compared to other centers. We believe that
this finding is not confident due to lack of adequate number of
physicians. Physicians working more than 2 years have a higher number of
CPR performances and so these physicians are more in dialog with
patients/relatives as their team leader roles. This may explain the
higher rates of DNAR demand of relatives.

Legal obligations for DNAR are not fully determined in our country (17).
In couple of protocols signed with other countries entitle patients with
right of DNAR whereas in some other protocols, patient him/herself is
not permitted to end his/her life (18). There are a lot of similar
situations. Best step towards bias is to specially work on only DNAR
term and concrete legal obligations should be gathered. Currently DNAR
performance and euthanasia are illegal and are punished as ``first
degree murder'' {[}defined in law number 181; clause 43{]} in Turkey
(19). For this reason, the CPR rate is high but the success rate is low
in Turkey. There is not a national statistical data in our
country.\textsuperscript{5} In most countries DNAR orders are legally
applicable. In our study, legal limitation is found to be the most
determinant factor both for DNAR decision making, and sharing this
decision with the patient' relatives. Nevertheless, this causes
physicians secure their DNAR decision from the relatives and so
relatives cannot have a right to object or agree DNAR decision. At
field, slow codes which called `cosmetic CPR' is preferred as DNAR. In
our study, we had physicians who mentioned DNAR decision making but
these decisions did not reflect to records. Knowing inefficient CPR but
still continuing to perform CPR is a very big moral burden for
physicians. This situation causes moral burdens to all CPR team and
results in team trust.

Recently, it is observed that DNAR decision is more shared with
patient/relatives in Europe (20). In our study, acknowledgement rate of
the relatives is found very low. This tendency may result in neglect in
patient rights and patient respect. Probably, honor and respect is the
last but most important wish of a patient in the last moments (21).
However in countries like ours where DNAR is illegal, DNAR decision is
made without official recording and not informing the patient/relatives.
The two major limitations of DNAR decision making seem to be legal
problems and violence risks that physicians face in emergency theaters.
These occasions are observed in government hospitals and
education-training hospitals which is found to be statistically
significant. This finding may be explained as 1.the sociocultural levels
of patients admitting to government hospitals are relatively low and
2.the numbers of patients are much more higher compared to university
hospitals. In a country where physicians are get killed by patient
relatives, the insecurity of the physician for sharing DNAR decision is
understandable. In country where DNAR is not discussed due to religious
beliefs, doctors killed by patient's relatives are major hypocrisy. The
increasing number of malpractice cases also result in legal insecurity.

\textbf{CONCLUSION}

As a result; patients should be analyzed carefully and CPR should be
performed to those who will benefit the most. CPR should be directed
regarding the experiences obtained from previous unsuccessful attempts.
In this case, DNAR term is occurring; for DNAR decision legal confidence
should be guaranteed to physicians. In our country, with current legal
status, DNAR cannot be performed. DNAR is trialed equal to `first degree
murder'. However this situation does not prohibit patients that will not
benefit from medical support. In situations where the patient is assumed
to die eventually, using total effort result both financial and time
loss. Additionally utilizing all the resources to patients that will
definitely not benefit may also result in reduced time and effort for
those who may actually benefit. DNAR should be handled by a committee
that should define the norms and legal aspects should be renewed.
Necessary steps should be taken immediately; otherwise, physicians will
continue to perform ineffective CPR with a huge moral burden and the
rate of unsuccessful CPR will increase.

\textbf{References}

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