Early DNR orders: some thoughts about gender
February 28 2020
A new study has concluded that early DNR orders in ICU are associated with “fewer non-beneficial procedures and less perceived suffering and loss of dignity”. It came across my Twitter feed when Amit Arya – @AmitAryaMD – made some points about the findings as they relate to what he terms ‘a racial gap in end of life care’. He wrote:
“Alarmingly, non-white patients were more likely to have a late DNR, associated with more non-beneficial procedures as well as a less peaceful & dignified death. This is consistent with many other studies”. Many studies show that in fact, racial & ethnic minorities do not actually prefer more aggressive EOL care. Why are they more likely to receive it then? Disparities in communication and #palliativecare service delivery are driving differences in outcomes. Factors such as discrimination, language barriers & historical trauma have a cumulative effect, resulting in profound harm & suffering. We need greater recognition of structural & interpersonal racism as causes of inequitable outcomes at end of life.”
Absolutely. It also made me think about the gender issues in the paper which were not foregrounded in the paper or addressed in the discussion:
61% of the sample ‘were male’. This didn’t appear to be related to participation bias, but is reflective of the ICU population. A number of studies have shown that men are more likely than women to experience an ICU admission. This means that there has already been some gender selection relating to end of life decision-making before people get into the ICU. What implications does this have for the findings?
The study showed a significant association (p=0.031) between gender and DNR group. Men were more likely to have a late DNR (62.8%) or no DNR (61.3%). This is congruent with previous research showing that men are more likely to receive CPR than women. Which can be both a good thing (we know there’s a lot of unwanted and futile CPR administered) and a bad thing (there is evidence that outcomes for out of hospital resuscitation are better for men than women because of differential CPR rates).
Findings are consistent with research showing women are less likely to express a preference for end of life intervention, with some evidence that this relates to fears of ‘being a burden’. Previous caregiving experience is also likely to be pertinent here. Given the gendering of caregiving, women are more likely to understand the realities of the support needed to die at home.
The study used nurse assessments of dying to determine outcomes. But there was no discussion of the impact of having nurses (presumably predominantly women but not specified) doing the assessment on behalf of the patient? There is evidence that the gender of patients and clinicians influences discussions about end of life.
Are understandings of suffering and loss of dignity gendered? Probably. But I’m not aware of any research in this area.
And what about intersectionality? What would findings look like if analysed by gender AND race? And other factors, for example experience of poverty or sexual orientation? There is increasing acknowledgement that analysis by one social factor alone does not capture complexity, and can be harmful in occluding other potential determinants of discrimination.
Summary
Given concerns about the over-medicalisation of dying it is clear that gendered patterns of end of life care are likely to negatively impact both women and men. It is also clear that there is a lot more work to be done in terms of raising awareness of the need to attend to gender as a key determinant of end of life experience. If you are interested in interrogating research papers through a gender lens – for example when conducting systematic reviews – we’ve done some prep work for you 🙂
As ever, please email for a full text copy of any papers we talk about if you can’t access them.