Shifts towards Patient Autonomy in Do-not-resuscitate Decisions and its Effects on End of Life Care

• In Event: 201 - Section on Medical Sociology Paper Session. Applications and Practice of Medical Sociology

Abstract

Physicians face ethical challenges when there are conflicts between autonomy and beneficence, which is defined as acting in the best interest of the patient. Shared decision-making, where the patient and doctor form a partnership to decide on treatment plan, has emerged as a model on the spectrum in between medical paternalism and patient autonomy. In the US, there are significant variations in hospital policies regarding Do Not Resuscitate (DNR) decision-making. In the UK, it is standard practice for doctors to make unilateral decisions to institute a DNR order in situations where survival is unlikely. The aim of this study is to explore how the sociological transformation of the American medical profession affected a doctor’s ability to balance patient autonomy and the patient’s best interest in these decisions, using the UK as a basis of comparison. I further discuss how different legal frameworks shape their ethical values and clinical approach.

In-depth interviews were conducted with 58 internal medicine doctors across four sites. At each hospital, dominant modes of decision-making emerged that ranged from paternalistic, to shared decision-making, to patient autonomy focused. Doctors at paternalistic or shared decision-making dominant hospitals felt they could provide care that was in the best interest of their patient. Doctors at hospitals that prioritized autonomy more frequently perceived conflict between honoring autonomy and acting with beneficence. They sometimes felt moral distress over providing treatments that they felt was not in the best interest of the patient and perceived more conflict with patients regarding preferred resuscitation status.

Author

• Elizabeth W Dzeng, University of Cambridge