Open Access Open Access  Restricted Access Subscription Access

Junior doctors and limitation-of-care orders: perspectives, experiences and the challenge of dealing with persons with dementia

Janaka J Lovell, Aleece MacPhail, Nicola Cunningham, Margaret Winbolt, Carmel young, Tony Pham, Joseph E Ibrahim


Background/Objectives: Globally, junior doctors play a central role in completing limitation of care orders (LCOs). This study aims to guide improvement of LCO utility by ascertaining junior doctor perspectives, LCO experiences and identifying challenges encountered in LCOs for patients with dementia, a particularly complex patient group. 

Design/Setting/Participants: Qualitative data were collected through semi-structured interviews. Participants were registered medical practitioners who had graduated within the previous 3 years and were practicing in a hospital in Victoria, Australia.

Results: Nineteen junior doctors were interviewed between December 2013 and January 2015. Junior doctors were frequently involved in discussion and decision-making around treatment limitations and end-of-life care. Participants described inconsistent support, a lack of preparedness, a vague understanding of related hospital policies and inadequate knowledge and experience when it came to completing LCOs. Although participants acknowledged the additional nuances of capacity and prognosis assessment for patients with dementia, they did not feel that the processes for completing LCOs were significantly different for these persons. Many also recognised that decisions were often made without adequate consultation with the relevant stakeholders in this patient group.

Conclusion: The junior doctors in this study highlighted global challenges in providing appropriate end-of-life care, particularly when they are responsible for this role. To improve patient care and ensure the wellbeing of junior doctors, hospitals need to address gaps in training needs and supervision with respect to end-of-life care, as well as to implement policies that support consistent and informed use of LCOs.


Clinical challenges, dementia, healthcare, health policy, junior doctor perspectives, limitation of care orders, medical education, medical ethics, patient-centered care, person-centered healthcare

Full Text:



Findlay, G.P., Shotton, H., Kelly, K. & Mason, M. (2012). Time to intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an In-hospital cardiorespiratory arrest: A report by the national confidential enquiry into patient outcome and death. NCEPOD 2012. Available at:

Accessed 2 Jan 2016.

Spiller, J., Kiehlmann, P., Davison, H., Murphy, D. & Wilkie, R. (2012). NHS Scotland DNACPR and CYPADM integrated policies – development of quality measures. BMJ Supportive & Palliative Care 2 (Supplement 1) A11-A12.

Weissman, D. (2003). Policy Proposal: Do not resuscitate orders: A call for reform. Virtual Mentor 5 (1) pii.

Fritz, Z. & Fuld, J. (2010). Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects. Journal of Medical Ethics 36 (10) 593-597.

Cherniack, E. (2002). Increasing use of DNR orders in the elderly worldwide: whose choice is it? Journal of Medical Ethics 28 (5) 303-307.

Mohanti, B.K. (2009). Ethics in palliative care. Indian Journal of Palliative Care 15 (2) 89-92.

O’Keefe, S.T., Noel, J. & Lavan, J.N. (1993). Cardiopulmonary resuscitation preferences in the elderly. European Journal of Medicine 2 (1) 33-35.

Carmel, S. & Mutran, E. (1997). Preference for different life-sustaining treatments among elderly persons in Israel. Journals of Gerontology Series B, Psychological Sciences and Social Sciences 52 (2) S97-102.

Liddle, J., Gilleard, C. & Neil, A. (1994). The views of elderly patients and their relatives on cardiopulmonary resuscitation. Journal of the Royal College of Physicians of London 28 (3) 228-229.

Gunasekara, N.P., Tiller, D.K., Clements, L.T. & Bhattacharya, B.K. (1986). Elderly patients’ views on cardiopulmonary resuscitation. Age and Ageing 15 (6) 364-368.

Salins, N. & Jansen, W. (2011). Clinical audit on documentation of anticipatory 'Not for Resuscitation' orders in a tertiary Australian teaching hospital. Indian Journal of Palliative Care 17 (1) 42-46.

Sidhu, N., Dunkley, M. & Egan, M. (2007). "Not-for-resuscitation" orders in Australian public hospitals: policies, standardised order forms and patient information leaflets. Medical Journal of Australia 186 (2) 72-75.

Lamas, D. & Rosenbaum, L. (2012). Freedom from the tyranny of choice - teaching the end-of-life conversation. New England Journal of Medicine 366 (18) 1655-1657.

Siddiqui, M.F. & Holley, J.L. (2011). Residents’ practices and perceptions about do not resuscitate orders and pronouncing death: an opportunity for clinical training. American Journal of Hospice and Palliative Care 28 (2) 94-97.

Davey, B. (2001). Do-not-resuscitate decisions: too many, too few, too late? Mortality 6 (3) 247-264.

Australian Medical Council. (2013). Intern training – intern outcome statements. Australian Medical Council Limited. Available at: Accessed 18 Jan 2017.

Morgan, R. & Westmoreland, C. (2002). Survey of junior hospital doctors' attitudes to cardiopulmonary resuscitation. Postgraduate Medical Journal 78, 413-415.

Gorman, T.E., Ahern, S., Wiseman, J. & Skrobik, Y. (2005). Residents' end-of-life decision making with adult hospitalized patients: A review of the literature. Academic Medicine 80 (7) 622-633.

Mezey, M.D., Mitty, E.L., Bottrell, M.M., Ramsey, G.C. & Fisher, T. (2000). Advance directives: older adults with dementia. Clinics in Geriatric Medicine 16 (2) 255-268.

Fallowfield, L. (2001). An unmerciful end: Decisions not to resuscitate must not be left to junior doctors. British Medical Journal 323 (7321) 1131.

Brims, F.J.H., Kilminster, S. & Thomas, L.M. (2009). Resuscitation decisions among hospital physicians and intensivists. Clinical Medicine 9 (1) 16-20.

National Institute of Ageing. (2016). End of life: helping with comfort and care. Available at: Accessed 15th March 2017.

Cohn, S., Fritz, Z.B.M,, Frankau, J.M., Laroche, C.M. & Fuld, J.P. (2013). Do not attempt cardiopulmonary resuscitation orders in acute medical settings: a qualitative study. QJM: Monthly Journal of the Association of Physicians 106 (2) 165-177.

Volicer, L. (2005). End-of-life care for people with dementia in residential care settings. Alzheimer's Association. Available at: Accessed 4 August 2016.

Ibrahim, J.E., MacPhail, A., Winbolt, M. & Grano, P. (2016). Limitation of care orders in patients with a diagnosis of dementia. Resuscitation 98, 118-124.

Hayes, B. (2013). Clinical model for ethical cardiopulmonary resuscitation decision-making. Internal Medicine Journal 43 (1) 77-83.

Postgraduate Medical Council of Victoria Inc (Aus). (2014). Postgraduate medical council of victoria inc. annual report for the financial year ended 30 June 2014. Available at: Accessed 10 August 2008.

Chadwick, L.M., MacPhail, A., Ibrahim, J.E., McAuliffe, L., Koch, S. & Wells, Y. (2016). Senior staff perspectives of a quality indicator program in public sector residential aged care services: Australian health review, early view. Australian Health Review 40 (1) 54-62.

Kitching, F., Winbolt, W., MacPhail, A. & Ibrahim, J.E. (2015). Web-based social media for professional medical education: Perspectives of senior stakeholders in the nursing home sector. Nurse Education Today 35 (12) 1192-1198.

MacPhail, A., Ibrahim, J.E., Fetherstonhaugh, D. & Levidiotis, V. (2015). The overuse, underuse, and misuse of dialysis in ESKD Patients with dementia. Seminars in Dialysis 28 (5) 490-496.

MacPhail, A., Young, C. & Ibrahim, J.E. (2015). Workplace-based clinical leadership training increases willingness to lead: appraisal using multisource feedback of a clinical leadership program in regional Victoria, Australia. Leadership in Health Services 28 (2) 100-118.

Ibrahim, J.E., MacPhail, A., Chadwick, L. & Jeffcott, S. (2014). Interns' perceptions of performance feedback. Medical Education 48 (4) 417-429.

Pope, C., Ziebland, S. & Mays, N. (2000). Qualitative research in health care: Analysing qualitative data. British Medical Journal 320 (7227) 114-116.

Haverkate, I., van Delden, J.J., van Nijen, A.B. & van der Wal, G. (2000). Guidelines for the use of do-not resuscitate orders in Dutch hospitals. Critical Care Medicine 28 (8) 3039-3043.

Rasooly, I., Lavery, J.V., Urowitz, S., Choudry, S., Seeman, N., Meslin, E.M., Lowy, F.H. & Singer, P.A. (1994). Hospital policies on life-sustaining treatments and advance directives in Canada. Canadian Medical Association Journal 150 (8) 1265-1270.

Australian Medical Council. (2013). Intern training-Guidelines for terms. Available at: Accessed 18 Jan 2017.

Independent Review of the Liverpool Care Pathway (UK). (2013). A review of the Liverpool care pathway. Available at: Accessed 10 Jul 2016.

Foley, D. & Cunningham, C. (2011). Not for resuscitation: more harm than good? Irish Medical Journal 104 (9) 279-280.

Morrison, R.S. & Siu, A.L. (2000). Survival in end-stage dementia following acute illness. Journal of the American Medical Association 284 (1) 47-52.

Gjerdingen, D.K., Neff, J.A., Wang, M. & Chaloner, K. (1999). Older persons' opinions about life-sustaining procedures in the face of dementia. Archives of Family Medicine 8 (5) 421-425.

Perron, N.J., Morabia, A. & De Torrente, A. (2002). Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital. Journal of Medical Ethics 29, 364-367.

Illing, J.C., Morrow, G.M., Rothwell nee Kergon, C.R., Burford, B.C., Baldauf, B.K., Davies, C.L., Peile, E.B., Spencer, J.A., Johnson, N., Allen, M. & Morrison, J. (2013). Perceptions of UK medical graduates’ preparedness for practice: a multi-centre qualitative study reflecting the importance of learning on the job. BMC Medical Education 13 (34).

Baker, S. (2008). How many qualitative interviews is enough? National Centre for Research Methods (UK). Available at:

Accessed 5 Aug 2016.



  • There are currently no refbacks.