Nurses’ Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study

Round 1

Reviewer 1 Report

This cross sectional survey of the experiences and attitudes of physicians and nurses in a tertiary hospital in Taiwan provides information of interest to readers. However, the participant numbers are heavily weighted toward nurses (n = 132) vs. physician (n = 13) which effectively makes this study "Nurses Experiences and Attitudes Regarding Discussions with Patients and Family Members". I would suggest the analysis focus on nursing experiences and attitudes although comparison between physician and nursing attitudes would be of interest. I suggest this as I suspect there is a (probably significant) difference between the two groups.

Materials and Methods

Under 2.3 Measures

The listing of items, Line 112 to 138, would be more easily accessible to the reader as a tabulated Appendix with the questions listed 1), 2), 3), etc under Component 1, Component 2, Component 3. Note: Line 138 to 139 is redundant as previously stated in Line 110 to 111.

I would like to see a better explanation of the comparison rationale between the "Have you?" and "Would you?" questions for covariate analysis as this is not clear and is confusing.  

Results

Sections 3.1 and 3.2 read well and correlate to accompanying Tables.

Sections 3.3 and 3.4 need better explanation in Methods (see above) and in particular the covariate analysis needs to be more explicitly explained.

Some statements require more statistical support. For example, in Line 180 to 181 and Line 183 to 184 on older clinicians being less likely to have DNR discussions with patients or patients families a age cohort 5 or 10 year breakdown needs to be analysed and shown.

More can be made of component 3 questions in Results. The number of participants responding to each question should be shown. The main themes coming from these comments can then be included in the Results section. The current highlighting of n = 3 (Line 201 to 202) and n = 4 (line 202 to 204) comments is rather meaningless given a potential 145 respondents.

There could also be a comparison section on physicians and nurses (as above).    

Discussion

Reasonable.

Minor formatting changes required throughout.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

I congratulate de authors for the pertinence of the present paper. 

It is well accomplished and underlines the need to implement (and evaluate) measures to foster discussions on DNR and LST withdrawal decisions. 

I would only point out some doubts that came to me when reading your paper.

Line 127: 

Item 5. "What kind of LST withdrawal would you recommend to patients or their families?" was answered using possibility: 

    (…)

It is my perception that this item's meaning, in the scope of your paper, might need a better understanding.

Tables 3 and 4:

The variable “religious belief” was correctly described in table 1 according to its association with physician attitudes toward LST withdrawal found in the literature. However, this variable wasn’t included in table 4 (and neither in table 3).  Could you please describe if you tested the relation of this variable with the physicians’ and nurses’ attitudes toward discussions of DNR and LST withdrawal?

Line 199:

“Participants who said that they would discuss DNR or LST withdrawal when caring for terminally ill patients in the future” (n=?): as to better evaluate the number of patients that reasoned reducing patients’ suffering, maintaining patients’ dignity, helping them to have a good death (n = 33), and helping families prepare for the patient’s death (n = 3). This number can also give us a perception of how many participants excluded discussing DNR and LST withdrawal in the future. 

I hope that these points are not too picky and can add some plus to your work. I believe this paper is meritorious and I wish you the best success with it.

Thank you.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Revised manuscript addresses concerns.