Do Not Resuscitate” Orders: Current Practice and Factors Influencing Decision Making in Kenyatta National Hospital

Abstract

Background: Do Not Resuscitate (DNR) orders are not commonly in use in the Kenyan health care system and decision making surrounding these orders may be complicated by cultural, religious and societal influences. There is currently no clear policy framework or law in existence in Kenya on DNR. The decisions may be influenced by the health care provider‟s personal experience, relative‟s or next of kin‟s wishes, availability of resources or even knowledge of the options available. The use of such orders is important for equitable use of limited resources. The lack of specific guidelines also exposes physicians to litigation, and may fail to take into account the patient‟s rights and express wishes. Study Objective: To describe the current DNR practice and factors influencing the care provider‟s decisions at Kenyatta National Hospital. Methodology: Study setting: Kenyatta National Hospital accident and emergency unit, inpatient wards, critical care units and theatres. Study Design: A descriptive, cross-sectional study. Study Population: Medical doctors involved in medical and surgical care, anaesthetists and anaesthesiology residents, surgeons and surgical residents. Data Collection: A structured self-administered questionnaire consisting of close-ended questions, and including participants‟ bio data, awareness about existing international resuscitation protocols such as those used jointly by the International Liaison Committee on Resuscitation (ILCOR) and use of these protocols in patient care. Data Analysis: Statistical analysis was done only on fully completed questionnaires. Descriptive statistics such as frequencies and percentages were used to describe the prevalence, knowledge level and practices of DNR orders. Simple correlation analysis such as Fischer‟s exact and chi-square tests were used to describe associations between independent variables and outcome variables. Level of statistical significance was set at a P-value of <0.05 for a 95% confidence interval. Study Utility: The purpose of conducting this study was to establish the current practice as regards DNR orders, while assessing the basis of this practice, with the aim of influencing any future efforts towards formulation of specific guidelines that serve to protect patient‟s rights and create a common practice within the institution. Results: The study demonstrated a low prevalence of DNR orders (21%), with those in the anaesthesiology field, and those in practice for more than 10 years, more likely to initiate these orders. The factors most considered in decision making included patient‟s diagnosis, disease severity and performance status, with lack of a legal framework being the biggest barrier to initiation of DNR orders. Conclusion: This study has demonstrated that most physicians practicing within KNH are not carrying out DNR orders, citing a lack of legal framework and guidelines as the main hindrance to initiating and executing these orders.