Do-not-resuscitate Discussion Research Articles

Factors related to do-not-resuscitate directives among critically ill patients in a medical intensive care unit

Objective: This study was to clarify the prevalence of do-not-resuscitate (DNR) and identify the factors related to critically ill patients who have DNR directives or not in a medical Intensive Care Unit (ICU) in Taiwan. Materials and Methods: A retrospective chart review of 100 critically ill patients expired between January and December 2012 were included. The outcome was DNR or not when patient expired. Other variables regarding patient's demographics, disease-and DNR-related information were recorded. Logistic regression model was used to assess the related factor about DNR. A P Results: DNR rates were 87%, and the mean interval from DNR signature to death was 3.9 days. Compared with the patients without DNR signature, the patients with DNR signature had no statistical significance of cancer diagnosis (odds ratio [OR] = 3.41, 95% confidence interval [CI] = 0.88-13.25, P = 0.076), and frequency of ICU admission (OR = 4.17, 95% CI = 0.92-18.86, P = 0.063). In addition, there were 4.22-fold (95% CI = 0.90-19.89) but no statistical significance ( P = 0.068) of the frequency of ICU admission by patients with DNR directives compared to those without DNR directives after adjusting the variables of age, gender, economic status, primary diagnosis, and level of consciousness. Conclusion: Although this study indicated no statistical significance, we found that a patient with a cancer diagnosis and more frequency of ICU admissions tended to influence on family members concerning DNR directives in clinical setting. Early initiation of palliative care and DNR discussion may enhance the quality of care for dying patients.

Jordanian critical care nurses' attitudes toward and experiences of do not resuscitate orders.

Do not resuscitate (DNR) decisions are an issue of considerable sensitivity for patients and their relatives, as well as health professionals. The aim of this study was to explore Jordanian critical care nurses' attitudes towards and experiences of DNR decisions in clinical practice. A cross-sectional survey design was used. The sample consisted of 111 nurses working in intensive care units in three government hospitals in Jordan. Fifty nine per cent of the participants were female. Most were under the age of 35 (69%) and 75% had a bachelor's degree. Most (67%) thought that the patient's family should be involved in DNR decision making. The majority (81%) reported that they preferred a coding system documenting DNR decisions in either the physician or nursing notes. Fifty eight per cent agreed that a standard DNR form should be kept with the patient's medical notes. Only 21% reported actual participation in DNR decisions. This study demonstrates that Jordanian critical care nurses are willing to participate in DNR discussions and decision-making processes. Each hospital in the country should have a written DNR policy to guide and discipline health-care providers' practice.

Documentation Quality of Inpatient Code Status Discussions

ContextAccurate documentation of inpatient code status discussions (CSDs) is important because of frequent patient care handoffs. ObjectivesTo examine the quality of inpatient CSD documentation and compare documentation quality across physician services. MethodsThis was a retrospective study of patients hospitalized between January 1 and June 30, 2011 with a new or canceled do-not-resuscitate (DNR) order at least 24 hours after hospital admission. We developed a chart abstraction tool to assess the documentation of five quality elements: 1) who the DNR discussion was held with, 2) patient goals/values, 3) prognosis, 4) treatment options and resuscitation outcomes, and 5) health care power of attorney (HCPOA). ResultsWe identified 379 patients, of whom 235 (62%) had a note documenting a CSD. After excluding patients lacking a note from their primary service, 227 remained for analysis. Sixty-three percent of notes contained documentation of who the discussion was held with. Patient goals/values were documented in 43%, discussion of prognosis in 14%, treatment options and resuscitation outcomes in 40%, and HCPOA in 29%. Hospitalists were more likely than residents to document who the discussion was held with (P < 0.001) and patient goals/values (P < 0.001), whereas internal medicine residents were more likely to document HCPOA (P = 0.04). The mean number of elements documented for hospitalists was 2.40, followed by internal medicine residents at 2.07, and non-internal medicine trainees at 1.30 (P < 0.001). ConclusionDocumentation quality of inpatient CSDs was poor. Our findings highlight the need to improve the quality of resident and attending CSD documentation.

DNR and ECMO: A Paradox Worth Exploring

Extracorporeal membrane oxygenation (ECMO) provides continuous circulation and/or oxygenation to adults with cardiac failure, pulmonary dysfunction, or both. The technology is similar to the traditional heart-lung bypass machines used during surgical procedures, however ECMO may be used outside the confines of the operating room and for extended periods of time. This paper explores the complexities, both clinical and ethical, of a do-not-resuscitate (DNR) order for patients with cardiopulmonary failure on veno-arterial (VA-ECMO), a type of ECMO that provides resuscitation superior to the chest compressions that DNR is intended to prevent. Clinically, a DNR order has limited utility for patients on VA-ECMO and its presence can serve to create confusion. Symbolically, however, the designation may serve as a stepping-stone for surrogates facing difficult end-of-life decisions. The paper concludes by suggesting that it is prudent to avoid DNR discussions in the context of VA-ECMO

Comparison of timing and decision-makers of do-not-resuscitate orders between thoracic cancer and non-cancer respiratory disease patients dying in a Japanese acute care hospital

The aim of the study was to compare timing and decision-makers of do-not-resuscitate (DNR) orders between patients with end-stage thoracic cancer and non-cancer respiratory diseases in a Japanese acute care hospital. This study retrospectively reviewed the medical records of patients who died between January 2008 and March 2013 in the Department of Respiratory Medicine of Osaka Police Hospital, a teaching and acute care hospital. We compared the decision-making process, especially timing and decision-maker, of DNR orders between patients with thoracic cancer and patients with non-cancer respiratory diseases. There were 300 cancer patients and 147 non-cancer patients. Cancer patients were significantly younger, were hospitalized more frequently and for longer, were more likely to have a DNR order placed earlier and decided in advance of last admission, and were more likely to have normal cognitive function at the time of the DNR order than non-cancer patients. Spouses of cancer patients were more likely to participate in DNR discussion. Only approximately 6 % of patients participated in DNR discussion in both groups. Cancer patients less frequently received aggressive treatment at the end of life (EOL) and were more likely to die in general wards than in intensive care units. Our study found that most Japanese patients, with or without cancer, who died in an acute care respiratory department, were not included in DNR discussions and that familial surrogates usually made the DNR decision at the EOL.

Clinician Perspectives Regarding the Do-Not-Resuscitate Order

While data exist regarding the frequency and timing of the do-not-resuscitate (DNR) order in children, little is known about clinician attitudes and behaviors regarding this order. To identify clinician attitudes regarding the meaning, implication, and timing of the DNR order for pediatric patients. Physicians and nurses from practice settings where advance care planning typically takes place were surveyed regarding their attitudes and behaviors about DNR orders. In total, 107 physicians and 159 nurses responded to the survey (N = 266). There was substantial variability in the interpretation of the DNR order. Most clinicians (66.9%) believe that a DNR order indicates limitation of resuscitative measures only on cardiopulmonary arrest. In reality, however, more than 85% believe that care changes beyond response to cardiopulmonary arrest, varying from increased attention to comfort to less clinician attentiveness. In addition, most clinicians reported that resuscitation status discussions take place later in the illness course than is ideal. Clinicians use the DNR order not only as a guide for therapeutic decisions during a cardiopulmonary arrest but also as a surrogate for broader treatment directives. Most clinicians believe that DNR discussions should take place earlier than they actually do. Interventions aimed at improving clinician knowledge and skills in advance care discussions as well as the development of orders that address overall goals of care may improve care for children with serious illness.

Code status discussion: Just have one

code status discussion between a physician and a patient with cancer. The 2 videos were the same except that 1 video ended with the physician recommending a do-not-resuscitate (DNR) order for his patient, deemed by the investigators to be the ‘‘beneficence approach,’’ whereas the other video ended with the physician eliciting his patient’s choice of code status by asking a question, described as the ‘‘autonomy approach.’’ Participating patients were randomized to the sequence in which the videos were watched (recommendation video first or question video first). First, a note about methods. The recognized limitation of this study’s method (having all participants view both videos, thereby serving as their own control and lowering the necessary sample size), is that responses to the second intervention are biased by the first. The investigators overcome this built-in bias by basing their conclusions about what influenced DNR choice only on participants’ responses to the first video. However, in their prior work using the same methodology to compare patients’ reactions to sitting versus standing physicians delivering ‘‘bad news,’’ 2,3 patients rated the second physician as more compassionate despite their overall preference for the sitting physician. No such shift was observed in this study. The investigators suggest the high degree of compassion exhibited by the physician in the video may have masked patients’ tendency to shift their perception of compassion, and its impact on their DNR choice. Another likely explanation for patients’ consistency is the often-found phenomenon that individuals are strongly biased toward being consistent in their choices 4 to avoid cognitive dissonance. 5 The investigators’ hypothesis, that patients would more frequently choose DNR for the patient in the first video when the discussion ended with a recommendation, was not supported. The type of ending did not appear to impact DNR choice. This result is surprising. It is well established in other contexts that a physician’s recommendation is influential and sometimes determinative of patients’ choices. 6-8 Why this different result within this context?

Patient–physician communication about code status preferences

Code status discussions are important in cancer care, but the best modality for such discussions has not been established. The objective of this study was to determine the impact of a physician ending a code status discussion with a question (autonomy approach) versus a recommendation (beneficence approach) on patients' do-not-resuscitate (DNR) preference. Patients in a supportive care clinic watched 2 videos showing a physician-patient discussion regarding code status. Both videos were identical except for the ending: one ended with the physician asking for the patient's code status preference and the other with the physician recommending DNR. Patients were randomly assigned to watch the videos in different sequences. The main outcome was the proportion of patients choosing DNR for the video patient. A total of 78 patients completed the study, and 74% chose DNR after the question video, whereas 73% chose DNR after the recommendation video. Median physician compassion score was very high and not different for both videos. All 30 of 30 patients who had chosen DNR for themselves and 30 of 48 patients who had not chosen DNR for themselves chose DNR for the video patient (100% versus 62%). Age (odds ratio = 1.1/year) and white ethnicity (odds ratio = 9.43) predicted DNR choice for the video patient. Ending DNR discussions with a question or a recommendation did not impact DNR choice or perception of physician compassion. Therefore, both approaches are clinically appropriate. All patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for the video patient. Age and race predicted DNR choice.

Patient-physician communication about code status preferences: A randomized controlled trial.

9049 Background: Code status discussions are important in cancer care. The best modality for such discussions has not been established. Our objective was to determine the impact of a physician ending a code status discussion with a question (autonomy approach) versus a recommendation (beneficence approach) on patients’ do-not-resuscitate (DNR) preference. Methods: Patients in a supportive care clinic watched two videos showing a physician-patient discussion regarding code status. Both videos were identical except for the ending: one ended with the physician asking for the patient’s code status preference and the other with the physician recommending DNR. Patients were randomly assigned to watch the videos in different sequences. The main outcome was the proportion of patients choosing DNR for the video patient. Results: 78 patients completed the study. 74% chose DNR after the question video, 73% after the recommendation video (p=NS). Median physician compassion score was very high and not different for both videos (p=0.73). 30/30 patients who had chosen DNR for themselves and 30/48 patients who had not chosen DNR for themselves chose DNR for the video patient (100% v/s 62%, p&lt;0.001). Age (OR=1.1/year, p=0.01) and white ethnicity (OR=9.43, p=0.004) predicted DNR choice for the video patient. Conclusions: Ending DNR discussions with a question or a recommendation did not impact DNR choice or perception of physician compassion. Therefore, both approaches are clinically appropriate. All patients who chose DNR for themselves and most patients who did not choose DNR for themselves chose DNR for the video patient. Age and race predicted DNR choice.

Discussing Religion and Spirituality Is an Advanced Communication Skill: An Exploratory Structural Equation Model of Physician Trainee Self-Ratings

Communication about religious and spiritual issues is fundamental to palliative care, yet little empirical data exist to guide curricula in this area. The goal of this study was to develop an improved understanding of physicians' perspectives on their communication competence about religious and spiritual issues. We examined surveys of physician trainees (n=297) enrolled in an ongoing communication skills study at two medical centers in the northwestern and southeastern United States. Our primary outcome was self-assessed competence in discussing religion and spirituality. We used exploratory structural equation modeling (SEM) to develop measurement and full models for acquisition of self-assessed communication competencies. Our measurement SEM identified two latent constructs that we label Basic and Intermediate Competence, composed of five self-assessed communication skills. The Basic Competence construct included overall satisfaction with palliative care skills and with discussing do not resuscitate (DNR) status. The Intermediate Competence construct included responding to inappropriate treatment requests, maintaining hope, and addressing fears about the end-of-life. Our full SEM model found that Basic Competence predicted Intermediate Competence and that Intermediate Competence predicted competence in religious and spiritual discussions. Years of clinical training directly influenced Basic Competence. Increased end-of-life discussions positively influenced Basic Competence and had a complex association with Intermediate Competence. Southeastern trainees perceived more competence in religious and spiritual discussions than northwestern trainees. This study suggests that discussion of religious and spiritual issues is a communication skill that trainees consider more advanced than other commonly taught communication skills, such as discussing DNR orders.

Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them

Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.

A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process

The Treatment Escalation Plan (TEP) was introduced into our trust in an attempt to improve patient involvement and experience of their treatment in hospital and to embrace and clarify a...

Characteristics of patients who refuse do‐not‐resuscitate orders upon admission to an acute palliative care unit in a comprehensive cancer center

Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit. A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis. Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P = .0005), nausea of 2 (0-7) versus 1 (0-4, P = .05), and dyspnea of 1 (0-5) versus 4 (0-7, P = .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P = .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P = .002) and with no advance directives (OR, 2.94; P < or = .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P < or = .0001). DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions.

Attitudes, experience, and factors associated with confidence regarding do-not-resuscitate practice.

e19597 Background: With increased number of advanced cancer patients, receiving do-not-resuscitate (DNR) permission became an important issue for oncology practice. This study aimed to explore attitudes, experience, factors associated with confidence regarding DNR practice among physicians. Methods: Cross-sectional, anonymous, online survey was conducted through a hospital's intranet system in a tertiary, large volume hospital in Seoul, Korea from October 29 to November 11, 2009. Following pre-notification letters, the survey was distributed to 1,243 physicians, and 559 (44.9%) of them (faculties 191, 34.0%; fellow 149, 26.6%; residents 149, 28.3%; interns 62,11.1%) completed the questionnaires. Results: There were 295 (52.5%) male physicians, the mean years of practice was 10.4 years, and only 13.4% (75) had education regarding DNR practice. Of total 326 (59.1%) had experienced DNR permission, the mean time of DNR practice was 18.7 minutes, and most frequently used places for DNR discussion were ward stations (27.4%, 154), counseling rooms (25.8%, 145), and corridors (22.3%, 125). Most of DNR permissions (95.4%, 309) were received from family members and only 3.7% (12) obtained it directly from patients. Physicians performed DNR practice with high confidence (average 8.7 out of 10 maximum). They also reported neglect attitude toward patients after DNR permission (average 3.4 out of 10 maximum). With univariate analysis, gender, status at the hospital, years of experience, previous DNR education were significantly associated with confidence regarding DNR practice, but only years of experience was significant in a multivariate model(p<0.05). Conclusions: The DNR practice was varied by physicians and years of experience was strongly associated with confidence regarding DNR practice. Systematic approach should be taken to discuss duration, place, and from whom physicians receive DNR. No significant financial relationships to disclose.

Prevalence and Related Factors of Do-Not-Resuscitate Directives Among Nursing Home Residents in Taiwan

To report the prevalence of Do-Not-Resuscitate (DNR) directives and to explore the factors associated with the presence of DNR directives among nursing home residents in Taiwan. A cross-sectional, correlation study. Seven nursing homes in southern Taiwan. Nursing home residents and their family surrogates. Data were collected using chart abstraction and a questionnaire survey. We used multivariate logistic regression to analyze the associations between resident, family surrogate, and facility characteristics and the presence of DNR directives. Among the 201 nursing home residents, 33 (16.4%) had DNR directives and 91% of the directives had been put in place by family surrogates. Our data revealed that resident's age (OR = 1.06, 95% CI = 1.01-1.12), cognitive function score (OR = 0.91, 95% CI = 0.85-0.97), prior DNR discussion between physician and family surrogate (OR = 4.09, 95% CI = 1.53-10.96), and nursing home with DNR policy (OR = 17.71, 95% CI = 5.87-53.46) were independently and associated with the presence of a DNR directive. The prevalence of DNR directives among Taiwanese nursing home residents was lower than that in other countries. Our results point out the lack of DNR policy in most Taiwanese nursing homes and highlight the need for policy makers to implement further regulations. Meanwhile, education about advance directives is warranted to increase public and professional awareness and to facilitate empowerment of the increasing number of frail elderly nursing home residents in Taiwan.

Survey of Do-not-resuscitate Orders in Surgical Intensive Care Units

End-of-life decisions are always difficult and complex, especially in the surgical setting. This study examines the epidemiology of do-not-resuscitate (DNR) orders, and the clinical factors influencing DNR consent. The impact of DNR on treatment and resource use in the surgical intensive-care unit (ICU) is also assessed. This retrospective observational study was performed at National Taiwan University Hospital, a tertiary medical center in Taipei. A total of 14,698 patients were admitted to the surgical ICUs between January 2003 and December 2006. Of these, 13,825 (94.1%) survived to ICU discharge and 873 (5.9%) died. Of those that died, 278 (1.9% of total patients) went home to die due to terminal stage illness and 595 (4.0 % of total patients) died in the ICU. All mortality patients were included in this study. Yearly DNR rates were all above 65%. The average interval from ICU admission to DNR consent remained stable at 11-13 days, but the interval from DNR consent to death increased over the study period, from 2.0 to 3.5 days. Discussion over DNR was mainly initiated by intensivists. Multivariate logistic regression analysis found that older age (odds ratio, 1.010; p = 0.017) was significantly associated with DNR consent. DNR patients had longer ICU stays, lower fraction of inspired oxygen, and less inotropic infusion, dialysis, transfusion, laboratory examination, and chest radiography, but more use of sedative drugs, analgesics, and nutrition support at the time of death. After DNR, the use of advanced antibiotics, chest radiography, laboratory examination, and transfusion decreased. Inotropic infusion, however, continued to significantly increase. Although DNR was common in our surgical ICU patients, this request was signed late in the ICU course, when therapeutic options had been exhausted. Early initiation of DNR discussion should be promoted to improve end-of-life care and reduce futile treatments in the ICU.

The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act

Background:Since the passage of the Patient Self-Determination Act, numerous policy mandates and institutional measures have been implemented. It is unknown to what extent those measures have affected end-of-life care, particularly...

Beliefs and attitudes of nurses and physicians about do not resuscitate orders and who should speak to patients and families about them

Both physicians and nurses play important roles in discussing do not resuscitate (DNR) orders with patients and surrogates. However, the beliefs and attitudes of health professionals about the role nurses should play in this process have received little systematic study. An anonymous survey was conducted of 217 attending internists, 132 medical house officers, and 219 staff nurses working on the medical floors and units at two teaching hospitals about their beliefs, attitudes, and confidence regarding DNR discussions. Attendings and house officers were more likely than nurses to believe that nurses should never initiate DNR discussions (p < .001). Nonetheless, 69% of both physician groups agreed that nurses should be allowed to do so. Nurses were the most likely of the three groups to consider DNR discussions rewarding clinical experiences (p < .001). In a multivariate ordinal regression model controlling for sex, attitudes about DNR discussions, and confidence in discussing consent for medical procedures, nurses were less confident than attendings (p = .04) but more confident than house officers in their ability to discuss DNR orders (p = .02). Staff nurses were more likely than their physician colleagues to believe they should be allowed to initiate DNR discussions, were more confident in their ability to discuss DNR than house officers, and had more positive attitudes. These results suggest further exploration of the role nurses should play in the DNR process.

Do-Not-Resuscitate Orders for Terminal Patients with Cancer in Teaching Hospitals of Korea

To examine the current practices relating to do-not-resuscitate (DNR) orders for terminal patients with cancer at teaching hospitals in Korea. The records of 387 deaths from January 1 to December 31, 2005 at four cancer centers were identified and reviewed to assess the DNR delineation. Basic demographics, circumstances surrounding the establishment of the DNR directive, the percentage of orders for identified populations, and the time interval between DNR consent and death were evaluated. An order of DNR consent was obtained from 296 patients (76%) of a total of 387 patients. All DNR consents were made between the physician and family, without involving the patient. Written preprinted DNR consent forms were used in 169 (57%) cases and 127 patients (43%) had verbal DNR permission. DNR consent was interpreted in two ways: one forbade resuscitation in two hospitals and the other implied limited care in two other hospitals. A unilateral physician decision to withhold cardiopulmonary resuscitation (CPR) was decided for 62 (16%) patients. Terminal CPR was performed on 29 (7%) patients. DNR discussion was made within 7 days of the day of death on 228 (77%) patient among the 296 DNR consenting patients. From our teaching-hospital-based analysis of terminal cancer patients in Korea, consent for a DNR order was common. However, DNR order forms were not standardized and lacked room to document patient involvement in the decision. Usually the DNR decision was made within last days of the patient's life. Our results reflect the need for the improvement of end-of-life care decisions in Korea.

The perceptions of do‐not‐resuscitate policies of dying patients with cancer

Patients in hospitals must authorize do-not-resuscitate (DNR) orders or the default cardiopulmonary resuscitation (CPR) occurs. Using discursive analysis, we examined the speech of 28 cancer patients, judged as within 3 months of death, to determine how they justified preferences for DNR orders. Most saw these as a positive outcome of not interfering with a natural death with the decision being personal and the legal right of a competent autonomous person. If surrogates were required, they needed knowledge of the medical facts and the patient's wishes. The doctor was crucial, while family although likely to be supportive may be burdened by the responsibility. Some favored an early DNR discussion, but the majority favored a later discussion when it was applicable. At interview, 58% patients had a DNR order, rising to 82% by the time of death. Written orders were favored, yet 9 of 21 who did not want CPR had no DNR order. Hope was mentioned spontaneously by 25 patients, both as a thing over which patients had little control and as the desire of a positive future outcome. If doctors' and patients' assessments of eligibility for DNR orders do not coincide, the process and documentation of decision-making needs revision.