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The 'Do Not Resuscitate' Order: A Profile of Its Changing Use

The 'Do Not Resuscitate' Order: A Profile of Its Changing Use Abstract • The "do not resuscitate" (DNR) order has wide-ranging ethical, legal, and economic implications. We reviewed the course of 244 patients who died during two three-month periods, in 1982 and 1986. We found that 68% of patients who died had a DNR order written, including 94% with malignancy and half of patients with cardiovascular disease. Most orders (61%) were written within three days of death, with 64% written on medical-surgical floors and 34% in critical care units. Even among patients under the age of 60 years, 57% had a DNR order written by the time of death. Ninety-one percent of DNR orders were written by attending physicians, with accompanying explanatory note in 84%. Documentation showed only 14% of patients but 77% of families being consulted. In 1983 a new two-level DNR order system defined two levels of intensity: "all but cardiopulmonary resuscitation" and "comfort measures only." Equal numbers of patients received each order in the 1986 sample. No patient was transferred to the critical care units after a DNR order had been written. The prevalence of DNR orders written for patients dying of cardiovascular disease increased from 27% to 64% over the four years. We conclude, from study of deaths in this representative community hospital, that an explicit DNR order is now the rule rather than the exception, but decisions are made late and involve family far more than the patient. (Arch Intern Med 1988;148:2373-2375) References 1. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Government Printing Office, 1983. 2. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1974;227( (suppl) ):833-868. 3. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1980;244( (suppl) ):453-509.Crossref 4. Rabkin MT, Gillerman G, Rice NR: Orders not to resuscitate. N Engl J Med 1976;295:364-366.Crossref 5. Miles SH, Cranford R, Schultz AL: The do-not-resuscitate order in a teaching hospital: Considerations and a suggested policy. Ann Intern Med 1982;96:660-664.Crossref 6. Paris JJ: Comfort measures only for 'DNR' orders. Conn Med 1982; 46:195-199. 7. Mahowald M, Schubert D, Gordon B: How one Ohio hospital resolved the DNR question: Cardiopulmonary resuscitation guidelines at Cleveland Metropolitan General and Highland View hospitals. Ohio State Med J 1986; 82:382-385. 8. Charlson ME, Sax FL, MacKenzie CR, et al: Resuscitation: How do we decide? A prospective study of physicians' preferences and the clinical course of hospitalized patients. JAMA 1986;255:1316-1322.Crossref 9. Lipton HL: Do-not-resuscitate decisions in a community hospital: Incidence, implications, and outcomes. JAMA 1986;256:1164-1169.Crossref 10. Schwartz DA, Reilly P: The choice not to be resuscitated. J Am Geriatr Soc 1986;34:807-811. 11. Uhlmann RF, McDonald J, Inui TS: Epidemiology of no-code orders in an academic hospital. West J Med 1984;140:114-116. 12. Levy MR, Lambe ME, Shear CL: Do-not-resuscitate orders in a county hospital. West J Med 1984;140:111-113. 13. Zimmerman JE, Knaus WA, Sharpe SM, et al: The use and implications of do not resuscitate orders in intensive care units. JAMA 1986;255: 351-356.Crossref 14. Crampton RS, Aldrich RF, Stillerman R, et al: Prehospital cardiopulmonary resuscitation in acute myocardial infarction. N Engl J Med 1972; 286:1320-1321.Crossref 15. Copley DP, Mantle JA, Rogers WJ, et al: Improved outcome for prehospital cardiopulmonary collapse with resuscitation by bystanders. Circulation 1977;56:901-905.Crossref 16. Bedell SE, Delbanco TL, Cook EF, et al: Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;309:569-576.Crossref 17. Cameron DJ, Mernick MH: Do-not-resuscitate orders. JAMA 1986; 256:2677.Crossref 18. Younger SJ, Lewandowski W, McClish DK, et al: 'Do not resuscitate' orders: Incidence and implications in a medical intensive care unit. JAMA 1985;253:54-57.Crossref 19. Elliott BA, Day TW, La Puma J, et al: 'Do not resuscitate' orders. JAMA 1986;255:3114-3115.Crossref 20. Starr TJ, Pearlman RA, Uhlmann RF: Quality of life and resuscitation decisions in elderly patients. J Gen Intern Med 1986;1:373-379.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The 'Do Not Resuscitate' Order: A Profile of Its Changing Use

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Publisher
American Medical Association
Copyright
Copyright © 1988 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1988.00380110039008
Publisher site
See Article on Publisher Site

Abstract

Abstract • The "do not resuscitate" (DNR) order has wide-ranging ethical, legal, and economic implications. We reviewed the course of 244 patients who died during two three-month periods, in 1982 and 1986. We found that 68% of patients who died had a DNR order written, including 94% with malignancy and half of patients with cardiovascular disease. Most orders (61%) were written within three days of death, with 64% written on medical-surgical floors and 34% in critical care units. Even among patients under the age of 60 years, 57% had a DNR order written by the time of death. Ninety-one percent of DNR orders were written by attending physicians, with accompanying explanatory note in 84%. Documentation showed only 14% of patients but 77% of families being consulted. In 1983 a new two-level DNR order system defined two levels of intensity: "all but cardiopulmonary resuscitation" and "comfort measures only." Equal numbers of patients received each order in the 1986 sample. No patient was transferred to the critical care units after a DNR order had been written. The prevalence of DNR orders written for patients dying of cardiovascular disease increased from 27% to 64% over the four years. We conclude, from study of deaths in this representative community hospital, that an explicit DNR order is now the rule rather than the exception, but decisions are made late and involve family far more than the patient. (Arch Intern Med 1988;148:2373-2375) References 1. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Government Printing Office, 1983. 2. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1974;227( (suppl) ):833-868. 3. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1980;244( (suppl) ):453-509.Crossref 4. Rabkin MT, Gillerman G, Rice NR: Orders not to resuscitate. N Engl J Med 1976;295:364-366.Crossref 5. Miles SH, Cranford R, Schultz AL: The do-not-resuscitate order in a teaching hospital: Considerations and a suggested policy. Ann Intern Med 1982;96:660-664.Crossref 6. Paris JJ: Comfort measures only for 'DNR' orders. Conn Med 1982; 46:195-199. 7. Mahowald M, Schubert D, Gordon B: How one Ohio hospital resolved the DNR question: Cardiopulmonary resuscitation guidelines at Cleveland Metropolitan General and Highland View hospitals. Ohio State Med J 1986; 82:382-385. 8. Charlson ME, Sax FL, MacKenzie CR, et al: Resuscitation: How do we decide? A prospective study of physicians' preferences and the clinical course of hospitalized patients. JAMA 1986;255:1316-1322.Crossref 9. Lipton HL: Do-not-resuscitate decisions in a community hospital: Incidence, implications, and outcomes. JAMA 1986;256:1164-1169.Crossref 10. Schwartz DA, Reilly P: The choice not to be resuscitated. J Am Geriatr Soc 1986;34:807-811. 11. Uhlmann RF, McDonald J, Inui TS: Epidemiology of no-code orders in an academic hospital. West J Med 1984;140:114-116. 12. Levy MR, Lambe ME, Shear CL: Do-not-resuscitate orders in a county hospital. West J Med 1984;140:111-113. 13. Zimmerman JE, Knaus WA, Sharpe SM, et al: The use and implications of do not resuscitate orders in intensive care units. JAMA 1986;255: 351-356.Crossref 14. Crampton RS, Aldrich RF, Stillerman R, et al: Prehospital cardiopulmonary resuscitation in acute myocardial infarction. N Engl J Med 1972; 286:1320-1321.Crossref 15. Copley DP, Mantle JA, Rogers WJ, et al: Improved outcome for prehospital cardiopulmonary collapse with resuscitation by bystanders. Circulation 1977;56:901-905.Crossref 16. Bedell SE, Delbanco TL, Cook EF, et al: Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;309:569-576.Crossref 17. Cameron DJ, Mernick MH: Do-not-resuscitate orders. JAMA 1986; 256:2677.Crossref 18. Younger SJ, Lewandowski W, McClish DK, et al: 'Do not resuscitate' orders: Incidence and implications in a medical intensive care unit. JAMA 1985;253:54-57.Crossref 19. Elliott BA, Day TW, La Puma J, et al: 'Do not resuscitate' orders. JAMA 1986;255:3114-3115.Crossref 20. Starr TJ, Pearlman RA, Uhlmann RF: Quality of life and resuscitation decisions in elderly patients. J Gen Intern Med 1986;1:373-379.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 1, 1988

References