{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T14:12:00Z","timestamp":1786543920479,"version":"build-2736575974"},"reference-count":55,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2023,3,22]],"date-time":"2023-03-22T00:00:00Z","timestamp":1679443200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"COMEC"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:p>Despite cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) decisions are increasingly considered an essential component of hospital practice and patient inclusion in these conversations an ethical imperative in most cases, there is evidence that such discussions between physicians and patients\/surrogate decision-makers (the person or people providing direction in decision making if a person is unable to make decisions about personal health care, e.g., family members or friends) are often inadequate, excessively delayed, or absent. We conducted a study to qualitatively explore physician-reported CPR\/DNAR decision-making approaches and CPR\/DNAR conversations with patients hospitalized in the internal medicine wards of the four main hospitals in Ticino, Southern Switzerland. We conducted four focus groups with 19 resident and staff physicians employed in the internal medicine unit of the four public hospitals in Ticino. Questions aimed to elicit participants\u2019 specific experiences in deciding on and discussing CPR\/DNAR with patients and their families, the stakeholders (ideally) involved in the discussion, and their responsibilities. We found that participants experienced two main tensions. On the one side, CPR\/DNAR decisions were dominated by the belief that patient involvement is often pointless, even though participants favored a shared decision-making approach. On the other, despite aiming at a non-manipulative conversation, participants were aware that most CPR\/DNAR conversations are characterized by a nudging communicative approach where the physician gently pushes patients towards his\/her recommendation. Participants identified structural cause to the previous two tensions that go beyond the patient-physician relationship. CPR\/DNAR decisions are examples of best interests assessments at the end of life. Such assessments represent value judgments that cannot be validly ascertained without patient input. CPR\/DNAR conversations should be regarded as complex interventions that need to be thoroughly and regularly taught, in a manner similar to technical interventions.<\/jats:p>","DOI":"10.1371\/journal.pone.0282270","type":"journal-article","created":{"date-parts":[[2023,3,22]],"date-time":"2023-03-22T17:36:01Z","timestamp":1679506561000},"page":"e0282270","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":12,"title":["Obstacles to patient inclusion in CPR\/DNAR decisions and challenging conversations: A qualitative study with internal medicine physicians in Southern Switzerland"],"prefix":"10.1371","volume":"18","author":[{"given":"Michele","family":"Bedulli","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ilaria","family":"Falvo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paolo","family":"Merlani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samia","family":"Hurst","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3537-0346","authenticated-orcid":true,"given":"Marta","family":"Fadda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,3,22]]},"reference":[{"key":"pone.0282270.ref001","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1097\/00005650-199704000-00003","article-title":"Changes over time in the use of do not resuscitate orders and the outcomes of patients receiving them.","volume":"35","author":"NS Wenger","year":"1997","journal-title":"Med Care."},{"key":"pone.0282270.ref002","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1136\/jme.2007.022772","article-title":"Patients\u2019 attitudes towards \u201cdo not attempt resuscitation\u201d status.","volume":"34","author":"AJ Gorton","year":"2008","journal-title":"J Med Ethics"},{"key":"pone.0282270.ref003","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1161\/01.CIR.98.7.648","article-title":"Resuscitation preferences among patients with severe congestive heart failure: results from the SUPPORT project. 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