Introduction

Do Not Resuscitate (DNR) or Do Not Attempt a (cardiopulmonary) Resuscitation (DNAR) is a medical order precluding cardiopulmonary resuscitation (CPR) in the event of cardiac and/or respiratory arrest. The use of DNAR orders has been increasing over the last decades and decisions regarding CPR and DNAR orders are increasingly considered an essential component of hospital practice [1]. Research shows that most patients would like to be consulted on these decisions [2, 3]. Furthermore, there is consensus that inclusion of patients in CPR/DNAR conversations can advance patient-centered care [4]. However, there is evidence that the necessary DNAR discussions between physicians and patients or surrogate decision-makers are often inadequate, excessively delayed, or absent [5]. This holds the risk of failing to adequately fulfill the two main intended purposes of DNAR orders, namely to act in accordance with patients’ (presumed) wishes and interests and prevent interventions that are considered “medically ineffective”, “medically inconsequential” or “medically harmful” with regards to the established goals of care [6].

Several reasons have been reported why physicians may avoid or be reluctant to hold CPR/DNAR conversations. Studies show that these conversations are extremely demanding for patients, surrogate decision-makers, and healthcare providers alike, and a potential source of conflict [5, 7]. Roadblocks include barriers related to patient and family factors (e.g., patients’ difficulty in accepting a poor prognosis or understanding treatment options, disagreement about goals of care, and lack of advance directives and/or decision-making capacity) [8], deficits in clinicians’ skills (e.g., feeling unprepared when conducting code status discussions due to lack of communication or negotiation skills) [9–11], clinicians’ beliefs (e.g., the belief that the patient is not in imminent danger of death or judgments regarding patients’ quality of life or prognosis) [12] and their anticipated emotions (e.g., feeling guilty for causing patient’s psychological distress or fear of litigation) [13]. Other obstacles include system/institutional limitations such as time constraints, lack of an appropriate opportunity to discuss end-of-life issues, and disagreement on who should be responsible for discussing DNAR issues [5, 14]. However, there is evidence that, even when DNAR/CPR discussions are initiated, physicians tend to conceal or manipulate certain information about the procedure and outcomes of CPR [15], resulting in patients having misconceptions regarding their likelihood of survival as well as the quality of the outcomes of CPR [16].

In Switzerland, the Swiss Academy of Medical Sciences (SAMS) published guidelines on CPR/DNAR decisions in 2021 [17]. According to these guidelines, CPR/DNAR decisions should be addressed carefully and at an early stage, i.e. before the acute situation arises that may lead to a cardiac arrest, and they should involve both the evaluation of the patient’s initial medical position and the determination of the patient’s wishes, goals, and expectations [17]. While patients should be actively involved in the decision-making process, the guidelines also recommend that whether the question of CPR is addressed more or less explicitly depends on the age, health status, and prognosis of the patient [17]. The public health crisis caused by COVID-19 reinforced physicians’ ethical obligations to protect the health of the public and to prudently steward limited resources. In April 2020, the American Medical Association (AMA) stated that it would be ethically justifiable for physicians to withhold CPR without seeking patients’ agreement during a public health crisis, as the goal is to maximize benefit (and minimize harm) for the greatest number of patients [18]. According to the AMA, the level of risk of exposure to health care personnel involved in the resuscitation and the risks that caregivers might in turn pose to others if infected are conditions that would make it ethically justifiable to place a DNAR order without patient involvement in the decision [18].

Pre-pandemic evidence from German-speaking Switzerland shows that more than 60% of patients did not recall having had a code status discussion during their hospital stay and more than 70% of physicians defined a DNAR status without prior discussion with the patient [19]. A survey of residents in charge of 206 patients including DNAR and CPR orders in the French-speaking region of Switzerland showed that participants cited the patients’ or their family’s resuscitation preferences as a major justification for placing a DNAR order in 18% of cases [20]. Participants justified patients’ inclusion in or exclusion from DNAR/CPR discussions using arguments based on respect for patient autonomy and decision-making capacity, as well as arguments based on their own clinical assessment of the patient [12]. Pre-pandemic evidence from the Italian-speaking region of Switzerland on physicians’ reasoning regarding CPR/DNAR decisions, and on the extent to which, why and how they include patients in these decisions, is currently missing. At a policy level, a decision support tool is available to physicians working in the four main hospitals in Ticino which clarifies the circumstances under which patients should be included in CPR/DNAR decisions (Ente Ospedaliero Cantonale’s internal document “D-SAN-004/B”). According to this tool, patient inclusion in the discussion is not essential if (1) the patient does not have functional limitations or major comorbidities, or if (2) the patient is approaching death. In the first case, the tool demands that a CPR order be given unless the patient explicitly refused cardiopulmonary resuscitation, while a DNAR code status should be included and implemented in the second case. Conversely, patient inclusion in the CPR/DNAR discussion is essential in all “intermediate situations”, e.g., with patients affected by comorbidities for whom death is not impending and for whom CPR attempts may bring some benefit.

In this latter setting, we conducted a study to qualitatively explore physician-reported CPR/DNAR decision-making approaches and CPR/DNAR conversations with patients hospitalized in the internal medicine wards of the four main hospitals in Ticino. In particular, the study has the objective of identifying possible tensions between the desired and actual decision-making approaches and conversations, accounting for the specificities of the current public health emergency caused by COVID-19. A tension can be defined as a situation that requires making a decision between two or more moral imperatives, neither of which is satisfactory or preferable, and where choosing one potentially results in transgressing the other(s) [21]. We decided to focus on Ticino and the hospital setting because evidence shows that advance directive completion in the Italian-speaking regions of Switzerland is at 17.9%, suggesting that the majority of CPR/DNAR decisions are addresses in the acute setting of the hospital [22].

Methods

Results

Characteristics of the sample

The final sample included 19 participants from the four main public hospitals in Ticino, of which 10 were women (see Table 1 for participants’ characteristics). Of the 153 potential participants invited in the study, 34 accessed the invitation survey and 30 provided their contact information. Response rate was RR = 12.4%. No reason was provided for non-participation. Participants’ mean age was M = 33.1 years (SD = 5.3). Mean age was M = 31.1 years (SD = 3.8) among residents and M = 39.2 years (SD = 4.6) among staff physicians. Among participants, 14 were resident physicians and 5 were staff physicians. Residents varied in the number of years of clinical experience, with most (n = 7) reporting 3–4 years of experience More than three quarters of the total sample (n = 15) did not have any postgraduate training in clinical ethics. The 4 participants reporting previous postgraduate training in clinical ethics included residents only.

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Table 1. Participants’ characteristics (N = 19).

https://doi.org/10.1371/journal.pone.0282270.t001

General description of the extracted themes

The analysis of the transcripts yielded three main themes. The first refers to the tension that participants reported between the ideal decision-making approach regarding CPR/DNAR and advance care planning, more generally, and the actual approach to patient involvement they experienced, which is described as being largely dominated by the belief that patient involvement is often pointless. Participants reported a number of justifications for this tension and proposed practical solutions to address it. The second theme refers to the tension between what participants regarded as ideal CPR/DNAR conversations with patients and how these actually unfold in their clinical experience; participants reported that they find themselves inevitably nudging patients rather than eliciting their preferences, an approach they justify through multiple explanations and for which they suggest a number of alternative practices. The third theme refers to the structural causes of this twofold tension: these include patient-provider-, policy-, culture-, and religion-related factors. Exemplary quotes from the focus group interviews can be found in Table 2.

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Table 2. Exemplary quotes from the focus group interviews.

https://doi.org/10.1371/journal.pone.0282270.t002

Discussion

The aim of this study was to qualitatively explore physician-reported CPR/DNAR decision-making approaches and CPR/DNAR conversations with patients hospitalized in the internal medicine wards of the four main public hospitals in Ticino. We found that CPR/DNAR decisions were dominated by the belief that patient inclusion is often pointless, even though participants had structured views on what would make a desirable decision-making approach. Moreover, we found that participants were aware that most CPR/DNAR conversations are characterized by a nudging communicative approach where the physician pushes patients to his/her recommendation, despite the belief that conversations should be as neutral as possible. Finally, participants identified structural causes to the previous two tensions that go beyond the patient-physician relationship. In the next paragraphs, we contextualize and interpret our findings, and consider their implications in light of the study limitations.

A first finding is the tension between a desired shared decision-making approach and the belief that patient involvement in CPR/DNAR decisions is often pointless, particularly when patients are deemed as lacking decision-making capacity. This finding, which echoes previous evidence that most physicians desire patient participation in the decision-making process and yet patients are often excluded [27], suggests two beliefs and a possible ex post rationalization behavior. The first belief is that patient involvement in the decision-making process can only be justified when CPR has an acceptable predicted success rate; if CPR offers little or no likelihood of benefit, patient involvement in the decision-making process offers little or no likelihood of benefit either and, therefore, there is no need to negotiate, and a unilateral DNAR is justified. This points to a pragmatic idea of value attributed to patient involvement: since it will not change the decision, there is no point in involving patients. That physicians’ own preferences may predominate in the CPR/DNAR decision-making process for their patients, and that they may not want their participation or believe that it is not necessary are both well documented [28–30]. Such a decision-making approach neglects two important elements. First, a decision to withhold CPR without knowing or even contrary to the patient’s or surrogate decision-makers’ wishes may only be justified in cases when CPR cannot reasonably be expected to yield the intended clinical benefit or achieve agreed-on goals for care, or when acute care facilities exceed functional capacity and triage decisions become necessary [17]. Even in such cases, competing concerns (e.g., risks of litigation) should be acknowledged by physicians. However, a unilateral DNAR is likely to be an ethical lapse: the decision may instead be driven by physicians’ perception that it is extremely difficult to involve patients in this choice, or by the fact that they do not “believe” that CPR is worth trying. Even when it becomes ethically justifiable to unilaterally make a decision to withhold CPR, patients still have an ethical and legal right to be informed about their code status and clinicians’ medical opinion and advice, and involved in other, more or less related decisions [31]. In addition, circumstances may change that make it necessary to review the CPR/DNAR status with patient input. The second element is that decisions regarding whether it is “worthwhile” to resuscitate represent, in the majority of cases, a value judgement rather than a matter of physiological probability, therefore any decisions regarding patient involvement in their CPR/DNAR decision-making will also constitute a judgment based upon a particular set of values that may contradict those of the patient affected [32]. There is wide consensus that it is extremely problematic to define the concept of futility in a medical context [33]. When recommending against CPR, physicians should approach such patients or their surrogate decision-makers with a presumption against providing CPR but also remain attentive when discussing the patient’s values and goals for unique factors and concerns that might make CPR unusually beneficial [34]. The second belief suggested by our participants’ reports is that decisions on whether to involve patients in the decision-making regarding their CPR/DNAR should be exclusively based on decision-making capacity criteria [35]. First, some have expressed concerns that these criteria are excessively “cognitive” and do not sufficiently attend to noncognitive aspects of choice and more demanding autonomy conditions relating to authenticity, narrative coherence, patient values, or the impact of volition, motivation, and affect or emotions (such as the emotional capacity to care) [36, 37]. Second, patients are generally presumed to have decision-making capacity, but the threshold (which should be that of ordinary freedom) tends to be shifted in opportunistic ways. A patient’s decision-making capacity may come under question when distortions in thinking and understanding due to a significant impairment of mental abilities are identified or suspected [38]. Only in such cases an assessment is warranted, and its results and underlying arguments need to be appropriately documented and made available to the patient, or the patient’s representative, on request [38]. However, dismissing patients as lacking capacity (e.g., because they struggle to understand factual information, as many participants of this study reported), may be the symptom of a post-rationalization behavior to legitimize a posteriori unilateral CPR/DNAR decisions taken by the care team. Physicians may ascribe incapacity because they see the possibility or even the likelihood of discovering disagreement between a patient’s preference and their recommendations/perspectives, and may feel ill-suited to handle such a conflict. According to the AMA, “physicians should engage patients whose capacity is impaired in decisions involving their own care to the greatest extent possible, including when the patient has previously designated a surrogate to make decisions on his or her behalf” [39]. In Switzerland, this is not only an ethical but also a legal requirement (Art. 377 of the Swiss Civil Code) [40]. Our participants were aware of these ethical and legal requirements, and many showed to be engaged with an active process of reflection on not only the reasons why, in practice, this is hardly met, but also possible solutions to resolve this tension. This finding does not surprise. Contrary to the rest of Switzerland, the Canton of Ticino borders with Italy, from which it is heavily culturally influenced. Paternalistic attitudes based on the therapeutic privilege are widespread [41]. CPR/DNAR discussion rates in this Canton are likely to be more analogous to rates detected in Italy than in German- and French-speaking Swiss Cantons [42].

A second finding is the reported tension between a desired non-manipulative conversation and the actual, leading communication style adopted by participants. This finding echoes the results of previous studies which found that, despite thoroughly trained on the importance of and ways to respect patients’ autonomy, physicians unintentionally resorted to strategic forms of communication leading patients to opt for physicians’ preferences [43, 44]. This result points to two facts. The first is the distinction between persuasion, nudging and manipulation. Persuasion refers to “believing in something through the merit of reasons another person advances”, and it is influenced by appeals to cognition rather than emotion [45], while manipulation refers to altering the quantity, quality, manner and relevance of the information presented to increase the effectiveness of a message in order to deceive or mislead the interlocutor [46]. The first may represent a valid support to patient autonomy, while the second a source of autonomy deprivation. Our participants reported to engage in a nudging communication. Nudging refers to intentionally structuring the presentation of options or decision-making environments to increase the frequency of desired choices without restricting free choice [47]. Scholars disagree on what would ethically justify nudging patients towards the decision that the physician believes to be the most desirable one. Some argue that nudging could amount to manipulation and improper exploitation of cognitive weaknesses [48–50], while others defend this practice as a form of “libertarian paternalism” that is not blind to cognitive biases in our judgments, and that in fact tries to “influence choices in a way that will make choosers better off, as judged by themselves”, by preserving freedom of choice and supporting moral agency [47, 51, 52]. Similar to all interventions that seek to direct behaviour towards certain ends, our participants were aware that nudging is problematic as it implies that physicians may impose their own judgment on what is beneficial to the patient, and may fail to address the reasons why CPR/DNAR may be the right thing for the patients. According to the SAMS guidelines on decisions on CPR, since discussions with patients and/or surrogate decision-makers will always also be influenced by personal attitudes and preferences, it is essential for physicians to be self-critical and aware of and disclose one’s own position [17]. Interestingly, our participants queried themselves against not only what ends they want to achieve (i.e., avoid nudging patients towards their personal preferences) but also what persons they want to be (i.e., the courageous, honest physician who guides patients in their decision-making without concealing or distorting the information on CPR). Such reflection shows that participants’ engagement of values and virtues was a central matter in their perspectives on CPR/DNAR conversation: who they are, what they recognize as important, and what they can (sustainably) achieve in relation to their CPR/DNAR conversations with patients are fundamentally intertwined. Participants reported a desire to engage in good action but they also made explicit the commitments underlying those actions. This is also stressed by the fact that they recognized the multidimensionality of the issue of nudging in CPR/DNAR conversations and reflected on multi-level solutions (e.g., involving general practitioners, offering young physicians ad hoc training to such conversations, or mobilizing social change to break the taboo around death that may hamper such discussion). The second elements suggested by this finding is that our participants may believe that there is only one, single-purpose conversation to be held with patients for whom CPR would offer little or no benefit. While a conversation on patients’ CPR preferences should be initiated when CPR represents an option, other conversations should take place when a cardiac arrest is likely and CPR is not offered. In this case, neither nudging nor other persuasive communication approaches will be needed. Rather, physicians should reassure patients that they will be respected and helped achieve the goals they have in pursuing their “loyalties”. This can be achieved by asking questions on their understanding of where they are with their health, their worries for the future, their hopes and priorities, and what they are (not) willing to sacrifice [53].

Finally, our participants called for a societal transformation in which each of us contributes to break the taboo of talking about death. However, it should be a priority for physicians to be able to overcome this taboo in clinical conversations, and learn how to not shy away from having difficult but important conversations about death with patients and families. Physicians often are unsure how to initiate or proceed with end-of-life discussions, mostly because medical education regarding end-of-life protocols is suboptimal or even lacking.

Our results have a number of implications which we summarise in the following list.

• First, they stress the importance of ensuring that CPR/DNAR conversations are held in the appropriate environment, with a trustworthy professional, and before the acute event presents. Ideally, GPs should be in charge of this conversation as they are likely to have established rapport with patients and can initiate these conversations outside of an emergency situation within the context of advance care planning. A national working group co-led by the SAMS and the Federal Office of Public Health (FOPH) is currently working towards improving the framework conditions and quality standards of advance care planning in Switzerland [54].
• Our results also stress the importance of recognizing that communication interventions in clinical practice should be regarded as complex interventions that need to be learned in a manner similar to technical interventions (actions that providers take and procedures they implement to deliver treatment and care to patients).
• From a policy point of view, our findings highlighted the limitations of the code status form currently implemented in the hospital where our participants were employed. Physicians land on the form as soon as the patient’s electronic health record is opened, and are asked whether CPR is indicated or not. In its current shape, this form may constitute a barrier to start a CPR/DNAR conversation and may nudge physicians to unilaterally decide on the patient’s code status. A better question could be “What are patient’s wishes regarding CPR?”. If a DNAR is entered, a question should appear asking “Has a decision been discussed?”.

This study has a number of limitations. First of all, the recruitment of participants was difficult to the point that it required adapting the design from in-person to online data collection. We thus relied on a small number of participants. However, participants engaged in an active and lively conversation during all four focus group, and brought such a richness of perspectives that it was possible to identify substantial tensions in relation to the themes explored. Second, given the low response rate, our sample was not representative of the hospital population we targeted. Furthermore, given that participation was on a voluntary basis, it may be possible that those who participated were particularly interested in the subject or with a particular discontent or tension that other non-participating physicians would have not highlighted had they joined the study. However, the issues raised by our participants remain relevant and interesting to understand the tensions experienced by resident and staff physicians and how they resolve them. Third, because of the small sample and the specific study aim, we cannot claim we reached thematic saturation. However, we relied on the concept of information power to establish saturation rather than thematic redundancy [55]. Information power indicates that the more information the sample holds that is relevant for the study, the lower number of participants is needed. Fourth, as this was the first exploratory study on CPR/DNAR decision-making and conversations in Italian-speaking Switzerland, we decided to restrict our target population to resident and staff physicians and exclude nurses and other professionals who have a role in CPR/DNAR decision-making and discussions. Finally, caution must be exercised in extending the findings of this study to clinical specialties other than internal medicine, outpatient settings, and different geographical areas, where different perspective on CPR/DNAR decision-making and conversations may emerge.

Conclusions

CPR/DNAR decisions are contextual and their symbolic meaning can be highly value laden. For these reasons, they represent judgments that cannot be validly determined without the patient’s contribution and that should be considered against the backdrop of a patient’s whole life story. Our results reiterate that making a CPR/DNAR decision requires initiating and holding potentially difficult conversations that even highly trained practitioners may feel ill-prepared for and uncomfortable with. Importantly, not only did our participants seem aware that imposing their views regarding CPR/DNAR on patients would be a case of abuse of power. They also queried themselves against the tension between acknowledging that patients can view their own good differently and choose otherwise than recommended, and the actual practice of respecting their views and wishes, as well as which virtues they want to embrace.

Supporting information

Acknowledgments

We thank all the resident and staff physicians who participated in the study. We would like to thank Prof. Enos Bernasconi and Dr. Tanja Fusi-Schmidhauser for their support in the recruitment phase of the study.