Wide variation in content of inpatient do-not-resuscitate order forms used at National Cancer Institute-designated cancer centers in the United States

Abstract

Determining resuscitation status (RS) for inpatients with advanced cancer is emotionally charged and often conflictual. Available data suggest that clinicians have inconsistent practices when establishing and documenting do-not-resuscitate (DNR) orders. Lack of standardization may contribute to ineffective and unclear discussions regarding RS. To inform revisions of DNR order forms used at one comprehensive cancer center, we surveyed National Cancer Institute-designated cancer centers (NCICCs) to determine if a standardized approach to documenting inpatient DNR orders exists. Over a 12-week period in 2002-2003, the 50 NCICCs providing inpatient care were contacted regarding participation in this Institutional Review Board-approved study. Using a 69-item database, inpatient DNR order forms were analyzed for content and elements of process used to establish and document RS. Each form was evaluated by two raters to assess inter-rater reliability. Analysis was descriptive; inter-rater agreement was summarized using the kappa statistic. Sixty percent (30 out of 50) of NCICCs participated. Eighty percent of responding sites confined the order process exclusively to cardiopulmonary resuscitation and did not include other interventions for possible limitation. Two thirds of responding sites used preformatted order forms specific for establishing inpatient RS; forms varied widely in content and elements of process used to establish and document DNR orders. NCICCs do not have a standardized approach to establishing and documenting DNR orders. Lack of standardization may reflect the absence of a common understanding of these difficult issues which may contribute to unclear and ineffective communication when addressing RS.