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.