The Impact of Do-Not-Resuscitate and Patient Care Category Policies on CPR and Ventilator Support Rates

Abstract

Cardiopulmonary resuscitation (CPR) is automatically provided in the event of a cardiac or pulmonary arrest, unless an order not to resuscitate is written. When successful, CPR usually leads to mechanical ventilatory support. A patient care category (PCC) policy, which replaces a do-not-resuscitate (DNR) policy, assigns a category on admission describing care to be provided. This PCC policy is perceived to avoid more unnecessary or undesired medical care that includes CPR and subsequent mechanical ventilatory support than a DNR policy. To compare total rates of CPR and days of mechanical ventilatory support before and after instituting DNR and PCC policies. A 7-year (1984 through 1990) retrospective review of rates of CPR and days of mechanical ventilatory support (DVS) in a community-teaching hospital was conducted. Two years were considered the baseline in which an institutional order not-to-resuscitate policy was nonexistent. Two years were during which an institutional DNR policy existed. Three years were during which an institutional PCC policy replaced the DNR policy. Compared with baseline years, during the DNR years mortality increased (8%), and CPR (-17%) and DVS (-8%) per 1000 admissions and CPR per 100 deaths (-26%) decreased. Compared with baseline years, during the PCC years mortality was unchanged and CPR (-61%) and DVS (-46%) per 1000 admissions and CPR per 100 deaths (-60%) decreased. Compared with DNR years, during the PCC years mortality (-8%), CPR (-53%), and DVS (-42%) per 1000 admissions and CPR per 100 deaths (-46%) decreased. A DNR policy significantly decreases the rates of CPR and DVS, but only modestly. A PCC policy dramatically decreases the rates of CPR and DVS with no change in mortality.