A comparative analysis of inpatient Do Not Resuscitate (DNR) forms used at National Cancer Institute-designated cancer centers (NCICC)

Abstract

8222 Background: The decision-making process establishing inpatient DNR status is difficult and may lead to conflict among the patient, family and clinician. In this study, we examined DNR forms from NCICC to determine content and process. Our goal was to summarize the range of currently accepted practice and frequency of specific components of inpatient DNR orders at NCICC in the U.S. Methods: Letters were mailed to NCICCs inviting participation in this IRB approved study, with repeat mailing at 4 weeks and follow up phone calls at 8 weeks. Stamped envelopes were provided for return of inpatient DNR order forms. 2 physicians (MD) evaluated each form for content and components of the process used to establish DNR. Descriptive analysis was performed using SAS. Results: 34/50 (68%) eligible sites responded and 30 (60%) participated. 67% of the participating sites used specific inpatient DNR forms; the remainder established DNR status exclusively by order sheets and without forms. 70% of form titles were negative in connotation, 30% neutral and none were favorable. 30% provided a definition of cardiopulmonary resuscitation or of DNR. 57% were confined exclusively to resuscitation efforts, with the remainder offering additional levels of treatment limitation. The majority of forms were indefinite in duration, with 20% time-limited. 25% specified exceptions for the operating room and 10% contained references to minors. Requirement for MD signature was universal, with 25% each also requiring patient and/or surrogate signatures. Additional requirements included documentation of persons involved in the decision (20%) and content of DNR discussion (67%). Conclusions: There is a wide range of practice in establishing DNR status at NCICC. Institutions were almost equally divided between addressing resuscitation exclusively versus resuscitation with limitation of other supportive therapies. Documentation of patient participation in the process is uncommon. A more consistent approach to addressing appropriate care options at the end of life could potentially facilitate decision making around this sensitive issue. No significant financial relationships to disclose.