DNAR Order Research Articles

95 Do Not Attempt Resuscitation: all or nothing?

Abstract Background Do Not Attempt Resuscitation (DNAR) orders may be implemented when patients do not wish to receive Cardio-Pulmonary Resuscitation (CPR) or when CPR is deemed non-beneficial. Complex ethical and medical considerations influence these decisions, emphasising the need for accurate documentation as per national policies. Our aim was to assess comprehensive documentation of DNAR decisions and healthcare providers’ opinions on managing patients with DNAR orders. Methods We conducted a point-prevalence chart review of adult inpatients with a DNAR order on March 2nd, 2023.We surveyed healthcare providers using a structured tool and analysed the data using Excel. Results We identified 22 (n = 22) charts for review. All charts had a DNAR form, but only 31.8% (7) had documented discussion details. 54.5% (12) lacked a discussion with the patient regarding the DNAR decision, and 58.3% (7) lacked documentation explaining the reasoning. 72.7% (16) lacked clear documentation on the reasoning for the DNAR status decision. Regarding healthcare providers’ opinions on patients with DNAR status, we received 46 completed questionnaires (n = 46). Most respondents believed simple bedside investigations and non-invasive interventions were appropriate for DNAR patients. However, there was a discrepancy in opinion regarding more invasive interventions, such as Naso-Gastric Tube placement (52%) or inotropic support (48%). 84.8% (39) of staff believe there is a distinction between palliative patients and those designated as DNAR. 80.4% (37) of nursing staff reported hesitancy in discussing DNAR status with doctors when patients deteriorate. 58.7% (27) of staff believed their approach to care changes when a patient is labelled DNAR. Conclusion Our audit demonstrates the need for improved DNAR status documentation. Current practices do not meet national guidelines, creating ambiguity and subsequent confusion during emergencies. This may be exacerbated by disparities in hospital staff opinion regarding DNAR patients, highlighting the importance of establishing local policies to improve staff education and patient care.

Usage of do-not-attempt-to-resuscitate orders in a Swedish community hospital \u2013 patient involvement, documentation and compliance

BackgroundTo characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation (CPR) and to describe patient involvement in, documentation of, and compliance with decisions on resuscitation (Do-not-attempt-to-resuscitate orders; DNAR).MethodsAll patients who died in Kalmar County Hospital during January 1, 2016 until December 31, 2016 were included. All information from the patients’ electronic chart was analysed.ResultsOf 660 patients (mean age 77.7 ± 12.1 years; range 21–101; median 79; 321 (48.6%) female), 30 (4.5%) were pronounced dead in the emergency department after out-of-hospital CPR. Of the remaining 630 patients a DNAR order had been documented in 558 patients (88.6%). Seventy had no DNAR order and 2 an explicit order to do CPR. In 43 of these 70 patients CPR was unsuccessfully attempted while the remaining 27 patients died without attempting CPR. In 2 of 558 (0.36%) patients CPR was attempted despite a DNAR order in place. In 412 patients (73.8%) the DNAR order had not been discussed with neither patient nor family/friends. Moreover, in 75 cases (13.4%) neither patient nor family/friends were even informed about the decision on code status.ConclusionsIn general, a large percentage of patients in our study had a DNAR order in place (88.6%). However, 27 patients (4.3%) died without CPR attempt or DNAR order. DNAR orders had not been discussed with the patient/surrogate in almost three fourths of the patients. Further work has to be done to elucidate the barriers to discussions of CPR decisions with the patient.

Sex Differences in “Do Not Attempt Resuscitation” Orders After Out-of-Hospital Cardiac Arrest and the Relationship to Critical Hospital Interventions

PurposeWomen who experience out-of-hospital cardiac arrest have similar rates of survival to hospital admission as men; however, women are less likely to survive to hospital discharge. We hypothesized that women would have higher rates of “do not attempt resuscitation” (DNAR) orders and that this order would be associated with lower use of aggressive interventions. MethodsWe identified adult hospital admissions with a diagnosis of cardiac arrest (ICD-9 427.5) from the 2010 California State Inpatient Dataset. Multivariable logistic regression was used to test the association between patient sex and a DNAR order within the first 24 h of admission, adjusting for patient demographic characteristics and comorbid medical conditions. In secondary analysis, procedures performed after establishment of DNAR order and survival to hospital discharge were compared by sex. FindingsWe analyzed 6562 patients (44% women, 56% men) who experienced out-of-hospital cardiac arrest and survived to hospital admission. In unadjusted analysis, more women than men had establishment of a DNAR order during the first 24 h of admission (23.4% versus 19.3%; P < 0.01). After adjusting for age, race, and comorbid conditions, women remained significantly more likely to have a DNAR order established during the first 24 h of their hospital admission after cardiac arrest compared with men (odds ratio = 1.23; 95% CI, 1.09–1.40). No sex difference was found in procedures used after DNAR order was established. ImplicationsFemale survivors of cardiac arrest are significantly more likely than men to have a DNAR order established within the first 24 h of in-hospital treatment. The establishment of a DNAR order is associated with patients undergoing fewer procedures than individuals who do not have a DNAR order established. Given that patients who have a DNAR order receive less-aggressive intervention after arrest, it is possible that an early DNAR order may contribute to sex differences in survival to hospital discharge.

The True Intention of Rescue Squads in Terms of the CPA Transportation of Cancer Patients in the Terminal Phase of the Disease Who Make a DNAR Order

The True Intention of Rescue Squads in Terms of the CPA Transportation of Cancer Patients in the Terminal Phase of the Disease Who Make a DNAR Order

The legal and ethical concepts of DNAR order in the out-of-hospital setting

The legal and ethical concepts of DNAR order in the out-of-hospital setting

End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis.

With population aging, “do not resuscitate” (DNAR) decisions, pertaining to the appropriateness of attempting resuscitation following a cardiac arrest, are becoming commoner. It is unclear from the literature whether using age to make these decisions represents “ageism.” We undertook a systematic review of the literature using CINAHL, Medline, and the Cochrane database to investigate the relationship between age and DNAR. All 10 studies fulfilling our inclusion criteria found that “do not attempt resuscitation” orders were more prevalent in older patients; eight demonstrated that this was independent of other mediating factors such as illness severity and likely outcome. In studies comparing age groups, the adjusted odds of having a DNAR order were greater in patients aged 75 to 84 and ≥85 years (adjusted odds ratio [AOR] 1.70, 95% confidence interval [CI] = [1.25, 2.33] and 2.96, 95% CI = [2.34, 3.74], respectively), compared with those <65 years. In studies treating age as a continuous variable, there was no significant increase in the use of DNAR with age (AOR 0.98, 95% CI = [0.84, 1.15]). In conclusion, age increases the use of “do not resuscitate” orders, but more research is needed to determine whether this represents “ageism.”

Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis

PurposeDo-not-attempt-resuscitation (DNAR) orders are common in severe sepsis, but the impact on clinical care is not known. Our primary objective was to determine the impact of early DNAR orders on in-hospital mortality and performance of key interventional procedures among severe sepsis hospitalizations. Our secondary objective was to further investigate what patient characteristics within the sepsis DNAR population affected outcomes. MethodsUsing the 2010-2011 California State Inpatient Dataset, we analyzed hospitalizations for adults admitted through the emergency department with severe sepsis. Our primary predictor was a DNAR order, and our outcomes were in-hospital mortality and performance of interventional procedures. ResultsVisits with early DNAR orders accounted for 20.3% of severe sepsis hospitalizations. An early DNAR order was a strong, independent predictor of higher in-hospital mortality (odds ratio [OR], 4.03; 95% confidence interval, 3.88-4.19) and lower performance of critical procedures: central venous line (OR, 0.70), mechanical ventilation (OR, 0.80), hemodialysis (OR, 0.61), and major operative procedure (OR, 0.46). Among those with early DNAR orders, older age and rural location were the strongest predictors for a lack of interventional procedures. ConclusionAlthough DNAR orders are not synonymous with “do not treat,” they may unintentionally limit aggressive treatment for severe sepsis patients, especially in older adults.

Performance of the efferent limb of a rapid response system: an observational study of medical emergency team calls.

AimTo determine the distribution of outcomes following a medical emergency team (MET) call using a modified version of the multidisciplinary audit and evaluation of outcomes of rapid response (MAELOR) tool, and to evaluate its usefulness in monitoring the performance of the efferent limb of the rapid response system (RRS) at our institution.MethodAn observational study of prospectively collected data including all MET calls at our institution during the 36 weeks study period (23 December 2013 – 31 august 2014). Outcomes of MET calls were registered 24 h after the call occurred and categorized according to the MAELOR tool.ResultsFifty-five of a total of 308 MET calls were excluded due to prior limitations in treatment. Of the remaining cases 66 % had positive outcomes. Thirty two percent of the calls resulted in transfer to the ICU, of these 73 % occurred within 4 h. Patients remained on the ward in 53 % of the cases, and 56 % of these were no longer triggering at follow up. Nine patients had died at follow-up, three without a DNAR order. Three patients were lost to follow-up, two patients were discharged from the hospital and 25 remained alive on the ward with a DNAR as a consequence of the MET call.ConclusionsICU transfer was implemented rapidly in most cases once the decision was made, but a disturbingly large number of patients, who remained on the ward were still triggering at 24 h follow-up. We found the MAELOR-tool useful to evaluate RRS efferent limb performance.

What sort of DNAR order is that?

There is considerable confusion over the status of ‘do not attempt resuscitation’ (DNAR) orders. David Tracey's claim against Addenbrookes hospital, in which he claims that the Trust unlawfully inserted a DNAR order into his wife's notes, without consulting with her or him, has brought the issue into the public eye.1 A DNAR order is a statement in the patient's notes to the effect that cardiopulmonary resuscitation (CPR) should not be attempted. This article analyses the legal status of such orders, and outlines some ethical and practical corollaries. ‘DNAR order’ is not a legal term: it refers to two types of direction which are legally very different. The first (which we will call ‘type 1’) is a clinical decision for a patient who lacks capacity: a decision that should be made in the patient's best interests at the time of cardiac arrest. The second (‘type 2’) is an advance decision to refuse resuscitation made by the patient when capacitous and binding on clinicians if valid, and if applicable to the circumstances.

심폐소생술 불필요(DN(A)R) 동의 취득에 대한 전공의 의식조사

This survey, which was conducted over the course of 3 months in 2009, was designed to investigate what the medical residents of one university hospital in Seoul think about DNAR orders. A total of 214 out of 468 residents (45.7%) answered the questionnaire. Participants were divided into two groups according to their experiences with taking DNAR order. There was no difference between the two groups on the definition of DNAR, its limitations, and when to issue DNAR orders. However, the two groups showed different opinions concerning who should be consulted in obtaining consent for DNAR and whether or not it was necessary to review DNAR orders. Residents who were experienced in giving DNAR orders felt more inclined to discuss the situation with the patient’s family members rather than the patient herself and thought that DNAR orders would not need to be reconsidered. These differences in opinion may result from the different experiences the two groups of residents had in actually ordering DNAR in the clinical setting. This study shows that more research and discussion is needed in order to establish the limitations and precise definition of DNAR orders.

To explore the factors influencing whether GPs sign the DNAR order as part of the LCP

BackgroundEnd of life care is currently a government and national priority. The Liverpool Care Pathway for the Dying Patient (LCP) is an evidence-based multiprofessional document which aims to optimise end...

Current status and physician's attitude toward advance care planning in hospice palliative care units in Japan

ObjectiveTo examine the current status and physicians' attitude toward ACP in PCU in Japan.MethodWe conducted a questionnaire survey and retrospective chart review of 203 certified PCU in December 2010.We received...

The over‐interpretation of DNAR

Purpose – The purpose of this paper is to investigate the impact of a “Do Not Attempt Resuscitation” (DNAR) order on subsequent decision making relating to the clinical care of the patient.Design/methodology/approach – The approach taken was a questionnaire based on a hypothetical clinical case, completed by medical and nursing staff of all grades in general medical, surgical, and orthopaedic wards.Findings – There is a reduction in the urgency attached to reviewing a deteriorating patient following institution of a DNAR order. Many doctors and nurses will not perform a range of interventions in the patient with a DNAR order in place. Confusion exists regarding whether an apnoeic, peri‐arrest patient should be ventilated when a DNAR order is in place.Research limitations/implications – This was a single‐centre study, looking at a hypothetical situation. Further studies at more centres, and investigating different designs of DNAR form, would clarify the best format for these to take.Practical implications ...

An Indecent Proposal: Withholding Cardiopulmonary Resuscitation

I n the February 20, 2008, issue of the Journal of the American Medical Association, Peberdy and associates reported an analysis of probabilities of survival from in-hospital cardiac arrest. Although their purpose was to examine whether outcomes differed according to the time and day of the week when the arrest occurred, their data raise other important questions about use of cardiopulmonary resuscitation (CPR). The current norm in acute care facilities is to assume that CPR should be performed in every case of cardiac arrest, unless a specific physician order to the contrary is in place. In this column, I propose a reversal of this; that is, I propose that in every case of cardiac arrest, unless a specific physician order to the contrary is in place, CPR should be withheld.

‘Do not attempt resuscitation’ orders in the peri‐operative period

‘Do not attempt resuscitation’ orders in the peri‐operative period

Prevalence of ‘do not attempt resuscitation’ orders and living wills among patients suffering cardiac arrest in four secondary hospitals

Objective: To assess the prevalence and implementation of ‘do not resuscitate’ orders, nowadays called ‘do not attempt resuscitation’ (DNAR) orders and living wills among patients suffering in-hospital cardiac arrest (CA) in whom cardiopulmonary resuscitation was not initiated. Materials and methods: A prospective survey of CA patients conducted in four secondary hospitals during 2000–2001. The information collected included the presence of DNAR and a living will and the patients sociodemographic and disease factors and the reasons for not initiating resuscitation when no DNAR order was present. Data on the resuscitated patients were collected according to the Utstein recommendations (analyzed and published separately) and used for comparison. Results: During the study period, 1486 patients suffered CA without resuscitation being initiated. Data collection was successful in 1143 patients (77%), who were included in the study. Most of the patients (84.5%) had a DNAR order. The prevalence of DNAR orders differed between the participating hospitals ( P<0.001), and between the wards of the hospital, with most DNAR orders in the cardiac care unit (100%) and medical wards (87%). The patients designated as DNAR were likely to be older ( P<0.01) and of poorer functional status ( P<0.001). Reasons for abstaining from resuscitation without a DNAR order were unwitnessed arrest (27%) and terminal disease (66%). Living wills were uncommon (1.5%). Patients with a living will were likely to have a DNAR order ( P<0.01). Conclusion: Most patients who suffered in-hospital CA without resuscitation had a DNAR order, and, for those who did not, terminal disease and medical futility were evident in most cases. Living wills were uncommon, but they appeared to have had some impact on treatment.

DNR Orders and Medical Futility-Reply

In Reply. —Our empirical study of the application of the medical utility rationale in DNAR by medical residents suggested this concept was not being used to avoid discussing end-of-life issues with patients or their families, but showed some important misunderstandings of quantitative and qualitative futility. Dr Epstein makes the good point that medical schools and postgraduate medical training programs do not adequately train students and residents in a number of important skills such as delivering bad news, providing informed consent, taking a sexual history, and discussing end-of-life issues. Further work is needed in each of these areas to identify methods that improve these skills. Dr Tomlinson and Ms Czlonka raise a specific concern with our analysis and interpretation of residents' understanding of quantitative and qualitative futility. We found that, for many patients, multiple rationales for the DNAR order existed. For example, for a given patient it was possible that the

DNR Orders and Medical Futility

To the Editor. —In the Editorial 1 regarding the study by Dr Curtis and colleagues, 2 Ms Alpers and Dr Lo note that the study may underestimate problems experienced at institutions without the bioethical experience of the setting of Curtis and colleagues. Specifically, I believe this to be true: in hospitals where physicians are not experienced with futility decisions, the becomes the predominant method of limiting the inappropriate use of CPR. A slow code is distinguished from other attempts at CPR by its purpose: to appear as a resuscitative effort but without the intention of therapeutic benefit for the patient. A slow code feigns medical therapy and serves nonmedical purposes such as avoiding the perceived legal risks of writing a DNAR order based on futility. During my residency training in internal medicine, completed in 1993 in New York City, the use of slow codes was common, while