Do-not-resuscitate Patients Research Articles

DNR in the Operating Room

After nearly two decades of experience, the proper circumstances and procedures for implementing do-not-resuscitate (DNR) decisions have become a standard of care throughout our nation. This standard recognizes not only that cardiopulmonary resuscitation sometimes offers no benefit and may actually harm patients, but also that competent patients have a right to refuse it. Moreover, physicians have an obligation to discuss resuscitation status with patients and their families and to document those discussions and the resulting treatment plan in the medical record. In this issue of<i>JAMA</i>, Walker¹identifies one important area of clinical practice where the application of DNR policy remains problematic— the operating room. At first glance, sending a DNR patient to the operating room may seem paradoxical. Yet, as Walker points out, terminal patients sometimes require palliative surgery. Furthermore, DNR patients need not be terminal; many of them live to leave the hospital

Preliminary Development of Two Predictive Models for DNR Patients in Intensive Care

The purpose of this study was to identify which variables are the best predictors of a do-not-resuscitate (DNR) classification and develop a model to predict the nursing care required by DNR patients in the ICU. Data collected on DNR and non-DNR patients included nursing care requirements, severity of illness, resource allocation and sociodemographic characteristics. One model identified the best predictors of a DNR classification in intensive care as the origin of admission and the severity of illness score on the day of admission to intensive care. The second model identified the best predictors of nursing care requirements for DNR patients in intensive care as the number of days spent in intensive care prior to the DNR order, the average daily resource allocation points after the DNR order, and the severity of illness score on the day the DNR order was designated.

DNR and Autopsy: A Linked Bayesian System

To the Editor.— The development of modern diagnostic techniques is perhaps the most important of several factors that have changed medical practice so that realistic and compassionate donot-resuscitate (DNR) orders are now commonplace. The careful evaluation that must precede a DNR decision anticipates the function of the autopsy and is, in fact, a form of autopsy (seeing for oneself). Thus, the autopsy approach to DNR patients begins with the use of diagnostic probes to secure aliquots and images of organs and tissues that provide more timely information than postmortem specimens. Information leading to a DNR decision coupled with postmortem data forms a linked Bayesian system in which the final posterior probability (P≈100%) of the primary disease is established before death. Because the postmortem part of the linked diagnostic system is limited to refining the principal diagnosis and turning up secondary diagnoses—pulmonary embolism, pneumonia, gallstones, and the like— that were not

Evaluation of the Do Not Resuscitate Orders at a Community Hospital

Demographic, medical, and outcome characteristics for 821 do not resuscitate (DNR) patients were compared with 300 age- and sex-matched control patients, and with 230 patients for whom cardiopulmonary resuscitation had been performed. Do not resuscitate patients were more likely to be female and older than cardiopulmonary resuscitation patients and to have a child as next of kin. Although DNR patients in intensive care units had comparable illness levels before and at the time of the order, treatment levels were reduced when the order was written. In general, DNR patients received more nursing care than other patients. Hospital mortality was 59.8% for DNR, 83.9% for CPR, and 1.7% for control patients. We identified diagnosis, prior activity, hospital unit, and employment status as predictors of DNR. According to documentation, 20% of patients participated in the DNR decision. Introduction of a DNR progress note form significantly improved documentation of the DNR process, but further efforts to improve DNR practice and patient participation are recommended.

Aggressiveness of Nursing Care For Older Patients and Those With Do-not-Resuscitate Orders

Age and do-not-resuscitate (DNR) orders were experimentally manipulated with a 2 X 2 factorial design using four vignettes which were randomly assigned to 95 staff nurses from four sites in a mid-Atlantic metropolitan area. Attitudes toward aggressiveness of nursing care were measured using the same 13-item 6-point Likert scale with all vignettes. Two replications with 183 nursing students and 86 intensive care nurses from six sites followed. Both increased age and DNR orders significantly, p less than .05 and .01, reduced aggressiveness of nursing care attitudes in all three studies. However, attitudes toward care still remained in the moderately aggressive range, which is more aggressive than current patient classification systems describe for DNR patient care.

The choice not to be resuscitated.

We studied the use of the do not resuscitate (DNR) order among general medical patients. During the six-month study period, of 2431 admissions there were 95 patients (3.9%) declared DNR. Of 105 deaths, 69 (66%) occurred among DNR patients. Twenty-seven percent of the DNR patients left the hospital alive. In 90% of the cases the medical intern initiated the DNR discussion, and in 60% of the cases a decision was reached in less than 24 hours. Two-thirds of the DNR orders were consented to by family members, and one-third of all DNR orders had a discernible impact on nonresuscitative care. Less aggressive therapy accounted for 60% of these restrictions, whereas the remainder involved limitations in diagnostic evaluations. When compared with age- and sex-matched general adult inpatient control subjects, DNR patients were found to have longer hospitalizations (P = .01), be more likely to reside in a nursing home (RR = 4.2), have a metastatic neoplasm (RR = 3.6), and be admitted with an abnormal mental status (RR = 6.1) or urinary incontinence (RR = 2.9). These differences remained significant when we controlled for the presence of a metastatic neoplasm. Despite a high in-hospital mortality rate (73%), DNR patients were not admitted more frequently than controls to the intensive care unit. We conclude that the DNR decision is based on clinical prognostic indexes and that once established, this order serves to modify the allocation of medical resources.

Do-Not-Resuscitate Orders for Critically III Patients in the Hospital

We studied compliance with do-not-resuscitate (DNR) orders at a university hospital where a DNR protocol has existed since 1979. Documentation of DNR status in patient progress notes and chart orders increased through 1983. During a 12-month period (March 1983 through April 1984), we studied in detail the medical records of 521 patients who had a cardiopulmonary arrest in the hospital. Seventy-five percent (389 of 521) of these patients were designated DNR. Patients who were designated DNR were significantly more likely to be older, to have malignancy or an abnormal mental status, and to be less likely to have acute myocardial infarction, stroke, or chronic obstructive pulmonary disease than patients in whom resuscitation was attempted. Eighty-six percent of families, but only 22% of patients, were involved in the decision to designate a patient DNR. The decision to designate a patient DNR occurred late in the course of a patient's illness, often when the patient was in coma. For 28% of patients, some form of medical care was withdrawn or withheld after they were designated DNR. These data suggest that use of the DNR protocol requires changes if patients are to participate in the decision not to undergo cardiopulmonary resuscitation.

The Do-Not-Resuscitate Order in Teaching Hospitals

We studied the use of do-not-resuscitate (DNR) orders at three teaching hospitals that did not have official protocols for such orders to see whether their use meets the goals (decision making before a crisis and promoting patient autonomy) that have been identified for such orders. We found that 20% of all patients had or were being considered for DNR orders, that the patient and/or family was usually involved (83%) in the decision not to resuscitate, but rarely involved (25%) in decisions to resuscitate, or in cases of no decision, that a wide range of care was provided to patients with a DNR status, and that partial resuscitative efforts would be employed in some cases. Our main conclusion in light of our findings is that DNR orders are currently not fulfilling their major goals. We offer six proposals for improving future DNR protocols.