Do Not Resuscitate orders and older patients: findings from an ethnographic study of hospital wards for older people

Background and aim. This paper reports on the findings from an ethnographic study involving three wards in two hospitals in the Northwest of England and focuses on the controversial issue of Do Not Resuscitate (DNR) orders. The study aimed to explore the way in which terminal care was provided to older patients and examined the way in which DNR orders were a socially constructed part of the practices of both nurses and doctors. Method. An ethnographic approach was adopted that used participant observation and semi-structured interviews with nurses and doctors. A purposive sample of 28 qualified nurses and five medical staff were interviewed. The decision-making process of DNR orders became the focus of the interview questions. Findings. The findings reveal that DNR decision-making was largely socially constructed from the interactions of hospital staff. Patients were not asked their preference and were excluded from any decision-making about Cardiopulmonary Resuscitation (CPR) or DNR orders. Two major findings emerge. First, DNR orders and the non-use of CPR could be seen as a form of medical beneficence, resulting from the often described paternalistic attitudes of hospital doctors. Second, there was a clear indication that DNR orders and the non-use of CPR for certain patients was based on improving the quality of patients' lives. Conclusion. The study raises issues about the quality of care received by frail older patients whom the nurses felt would not survive a futile medical procedure. The conclusion considers the need for hospitals to formulate and implement CPR policies, particularly in the prevailing climate in which patients are encouraged to become active participants in their own health care.