Do-not-resuscitate order after 25 years*

Burns, Jeffrey P.; Edwards, Jeffrey D.; Johnson, Judith A.; Cassem, Ned H.; Truog, Robert D.

doi:10.1097/01.ccm.0000064743.44696.49

Cited by 169 publications

(117 citation statements)

References 47 publications

Supporting

Mentioning

105

Contrasting

Unclassified

Order By: Relevance

“…Many medically ill patients support euthanasia 30,31 , but this remains a controversial subject among physicians 32 . DNR orders are legally and ethically acceptable 33,34 , and should not be confused or conflated with euthanasia or physician assisted suicide. Physicians who are faced with an apparently illogical request for FC should explore concerns about euthanasia.…”

Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

View full text Add to dashboard Cite

BACKGROUND:The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS:We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS:We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

show abstract

Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

View full text Add to dashboard Cite

show abstract

“…In patients whose prognoses are so poor that they are not expected to derive benefit from cardiopulmonary resuscitation, or in patients whose values and preferences are against aggressive resuscitation, DNR order sallow caretakers to potentially reduce patient suffering, comply with patient wishes, and rationalize the delivery of healthcare. 5 As such, understanding the factors that influence DNR orders and making their implementation more effective has the potential to improve the care of criticallyill patients with sepsis.…”

Section: Introductionmentioning

confidence: 99%

Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

Chang

Brass

2014

J GEN INTERN MED

View full text Add to dashboard Cite

BACKGROUND: Identifying factors associated with donot-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed. METHODS: A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders. RESULTS: Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order. CONCLUSION: Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .KEY WORDS: end-of-life care; healthcare delivery; epidemiology.

show abstract

“…17 Furthermore, the patterns of DNR orders suggested that physi-cian-and institution-related biases had a stronger influence on the timing and selection of patients for DNR orders than patientrelated factors such as the presence of advance directives. 18,19 Although problems with DNR orders have been discussed for decades, substantial efforts at reform proved inadequate. Fortunately, the recent health care reform has created a national impetus to promote safe, high quality care and eliminate costly, ineffective treatments.…”

Section: Introductionmentioning

confidence: 99%

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

2011

View full text Add to dashboard Cite

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 selfdetermination and avoiding non-beneficial interventions at the end of life.KEY WORDS: do-not-resuscitate orders; informed consent; end-of-life care.

show abstract

Do-not-resuscitate order after 25 years*

Cited by 169 publications

References 47 publications

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

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

Contact Info

Product

Resources

About