Changes over time in the use of do not resuscitate orders and the outcomes of patients receiving them.

Abstract

Do not resuscitate (DNR) orders are increasingly common, though there has been little evaluation of their changing use. The authors contrasted the use and outcomes of DNR orders for nationally representative samples of Medicare patients hospitalized with specific diagnoses in 1981 to 1982 and 1985 to 1986. Using ordinary least squares regression to adjust for patient and hospital characteristics, the authors compared use, timing and predictors of DNR orders, and survival to hospital discharge of patients with DNR orders between the two time periods. After adjustment for sickness at admission and for patient and hospital factors, more patients received DNR orders in 1985 to 1986 than in 1981 to 1982 (13% versus 10%, P < 0.001), with most of the increase among patients with the greatest sickness at admission. Disparity in DNR order use by age, diagnosis, functional status, preadmission residence, and gender found in 1981 to 1982 was still present in 1985 to 1986. DNR orders were written earlier in hospitalization during the latter time period. Patients with DNR orders were more likely to survive to hospital discharge in 1985 to 1986 than in 1981 to 1982 (44% versus 36%, P = 0.001), but their 30-day survival did not differ. Although use increased, disparities in DNR order assignment persisted in these 1980s data. Examination is needed into whether these differences persist and whether they reflect patient preferences. Systems should be developed to preserve and review the preferences of the increasing number of patients discharged after in-hospital DNR orders.