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.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.