Emergency department management and resource utilization in patients with Do-Not-Resuscitate orders

Abstract

Study objectives: The advent of the do-not-resuscitate (DNR) clause has brought with it comfort, anxiety, and sometimes anguish for patients, families, and health providers. To date, there is no information in the emergency literature describing practice patterns and treatment of patients with orders. The objective of this study is to determine whether there is a difference in the emergency department (ED) treatment or cost of in patients with DNR comfort care orders compared with patients with DNR general medical care or patients without orders. Methods: A retrospective, matched pair, case-control design was used. Medical records for all patients residing in extended facilities evaluated in the ED in 2002 were reviewed. After confirmation of DNR comfort care status, variables of interest were abstracted. Controls were matched on ED International Classification of Diseases, Ninth Revision diagnosis code, sex, age, and clinical acuity. Results: Review of 3,176 records resulted in 48 potential DNR–comfort cases. A total of 26 patients could be appropriately matched. There was no significant difference in the age between DNR–comfort and DNR–general medical groups (85.8 versus 81.5 years, respectively; P =.11). Sex and racial distributions were the same for both groups. As expected, an ambulance was used to transport more than 85% of patients but did not differ according to status ( P =.12). There was no difference in ordering CBC count, metabolic panel, or urinalyses ( P >.24). No difference in use of cranial or abdominal computed tomography was found ( P >.32). ED disposition and type of nursing unit on admission did not differ ( P >.61). Although the average hospital cost in DNR–comfort patients was lower ($8,323.29 versus $15,332.58), it did not reach statistical significance ( P =.10). Conclusion: In this small, single-center sample, there was no difference in the ED treatment, resource utilization, or cost of between DNR–comfort and DNR–general medical patients.