An interprofessional approach can further solidify the process by utilizing nursing and case management resources. Regardless, earlier and more complete discussions regarding a range of care preferences should be undertaken, and early involvement of a palliative care team may lead to better understanding of a DNR order. Minimal training in end-of-life discussions and exposure to palliative care patients at the medical school level is another barrier to physician comfort in end-of-life care. Physicians educated in the skills necessary to have the discussions have led to an increase in patient preferences at end-of-life. Despite the evidence, however, junior physicians report little formal education regarding palliative or end-of-life issues and have cited hospital culture as a deterrent to engaging and learning more about the subject. ![]() The questions noted above can also be used to guide the physician but do not specifically address DNR or DNI preferences. Gauging a patient’s or proxy’s understanding of the current condition and expectations can be a useful introduction to the discussion. It is paramount that all parties involve understand do-not-resuscitate does not mean all treatments are discontinued and standard of care is not hindered by a DNR order. Unfortunately, there may exist a notion that do-not-resuscitate equates to do-not-treat. For select hospitalized patients without advance directives or DNR/DNI orders, physicians may find the discussion difficult but necessary. According to one study, it may be beneficial to start with two simple questions: “If you cannot or choose not to participate in health care decisions, with whom should we speak?" and "If you cannot or choose not to participate in the decision-making, what should we consider when making a decision about your care?” Though these questions may help initiate a dialogue, they do not specifically address patient care preferences regarding DNR and DNI, and further detailed discussions are needed. It is important to specifically illicit patient preference regarding DNR and DNI during an advance directive discussion. Furthermore, some directives clearly specify exactly what is wanted for a given situation, while others, as noted above, remain vague. Though many advance directives include preferences pertaining to cardiopulmonary resuscitation, they are not equivalent to Do-Not-Resuscitate (DNR) or Do-Not-Intubate (DNI) orders. Advance directives are legal documents but are not medical orders. Initiating a discussion and implementation of an advance directive should include patient care preference regarding code status or cardiopulmonary resuscitation. Future interventions to improve knowledge need to focus on specific clinical knowledge about opioid therapy, as well as information about eligibility rules for hospice.Advance directives may vary by state, but all are designed to outline care preferences in the event one becomes incapacitated. Our findings identified misunderstandings that hospitalists and residents commonly have, including about facts essential to know in order to provide appropriate pain and symptom management. Physicians reported positive attitudes about hospice care as well as the belief that many patients who would benefit from hospice do not receive hospice at all or only late in the course of their illness. These myths pertained to essential aspects of end-of-life care including pain and symptom control, indications for various medications, and eligibility for hospice. Several common myths about treating terminally ill patients were identified. ![]() Data were collected using a 22-item survey instrument adapted from previously published instruments. ![]() In 2006 we conducted an exploratory study at a large academic medical center to examine the knowledge, attitudes, and practices of hospitalists and residents (n = 52, response rate = 85.2%) about the care of terminally ill patients. Although hospitalists and residents are often involved in the care of hospitalized patients with terminal illness, little is known about their knowledge and beliefs concerning terminal illness, despite the importance of such physicians to the quality of care at the end of life. Shortcomings in the quality of care of hospitalized patients at the end of life are well documented.
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