Elsevier

Journal of Critical Care

Volume 19, Issue 3, September 2004, Pages 135-144
Journal of Critical Care

An empirical analysis of the decision-making of limiting life-sustaining treatment for patients with advanced chronic obstructive pulmonary disease in Hong Kong, China

https://doi.org/10.1016/j.jcrc.2004.08.001Get rights and content

Abstract

Objectives: To understand the prognostic and quality-of-life considerations surrounding life-sustaining treatment decisions for patients with advanced chronic obstructive pulmonary disease (COPD) in Hong Kong China.

Methods: A documentary review of 49 COPD patients and 19 patient case studies from the medical departments of 2 hospitals were undertaken to examine the practices of DNI decision-making (do not perform mechanical ventilation and cardiopulmonary resuscitation). Statistical, event, and thematic analyses were conducted to delineate the prognostic and quality-of-life factors that shaped the not for intubation and mechanical ventilation (DNI) decisions.

Results: Three major treatment-limiting decision-making patterns existed in practice: 1) Patient-initiated and shared decision-making with physician (n = 14); 2) Physician-initiated and shared decision-making with the patient/family members (n = 24); and 3) Physician-initiated DNI decision-making with patient family, but without patient participation due to mental incapacity (n = 11). Prognostic considerations include physiological parameters, performance status, concomitant diseases, therapeutic regimens, and the utilization of medical services. Three major themes were delineated regarding the way in which the patients evaluated their life quality in the context of DNI status. They are prognostic awareness, illness burdens, and existential concerns.

Discussion: A decision-making framework used by patients/families/physicians to limit life-sustaining treatments in patients with advanced COPD is delineated. Observations regarding how treatment limiting decision-making for patients with advanced chronic illnesses can be improved in Hong Kong are discussed.

Section snippets

Multiple-case studies design

The study design is based on Yin’s case study method.17 It is a research strategy that involves carrying out an empirical inquiry using multiple sources of evidence to examine and represent individual experiences and group interaction within their social context. Triangulation of different data sources was employed to examine DNI practices in the medical departments of 2 hospitals. These hospitals belong to the same cluster under the Hospital Authority of Hong Kong. One is a comprehensive acute

Prognostic factors surrounding DNI decision-making

Of the 49 records under review, as outlined in Table 1, the patients’ average length of survival from the day of DNI decision to the day of death was 210 days (SD: 353.5, range: 1–1450 days). Eleven (22.5%) died within 1 week after the DNI decision was made, and 11 (22.5%) survived more than 1 year after the DNI decision was made. Three major DNI decision-making patterns were delineated. They are 1) Patient-initiated, and shared DNI decision-making with physician (P-S-D, n = 14); 2)

Discussions

Figure 1 summarizes the prognostic and quality-of-life considerations in DNI decision-making. The empirical analysis shows that three DNI decision-making patterns coexist in the practice context. Both P-S-D and D-S-P/F patterns have the patients actively engaged in the decision-making process. DNI decision-making is characterized by a consensus building process in which the patients, their families and healthcare providers come to a state of prognostic awareness that it is for the best

References (25)

  • G.H. Murata et al.

    A multivariate model for predicting respiratory status in patients with chronic obstructive pulmonary disease

    J General Intern Med

    (1998)
  • K. Nishimura et al.

    Clinical course and prognosis of patients with chronic obstructive pulmonary disease

    Curr Opin Pulm Med

    (2000)
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    This work was supported by the Research Grants Council of the Hong Kong Special Administrative Region, China (PolyU7257/00H)

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