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At least 19 recordsLinked to original sources
PubMed1993

Impact of a procedure-specific do not resuscitate order form on documentation of do not resuscitate orders.

BACKGROUND: Serious problems exist with respect to documentation of do not resuscitate (DNR) orders. We studied the impact of a procedure-specific DNR order form on documentation of these orders. METHODS: We prospectively compared DNR chart documentation during a 3-month period before and after implementation of a procedure-specific DNR order form. RESULTS: The order form was used in 41 (93%) of 43 charts after its implementation. Documentation of attending physician agreement with the DNR order form increased from 30 of 34 charts in which the order form was used). The number of orders where it was uncertain whether at least one component of acute cardiopulmonary life support-related procedures was to be performed decreased from 30 (88%) of 34 charts to three (7%) of 43 charts. The order form had no measurable impact on documentation of DNR discussion. Only 25% of the charts had any discussion of the risks and benefits of CPR. CONCLUSIONS: A procedure-specific DNR order form can improve documentation of DNR decisions. The reduction of uncertainty in these orders about the use of specific procedures can prevent errors in patient care.

Advance Directives↗
PubMed1995

Outcomes of patients with do-not-resuscitate orders. Toward an understanding of what do-not-resuscitate orders mean and how they affect patients.

OBJECTIVES: To evaluate the outcomes of hospitalized patients with do-not-resuscitate (DNR) orders and to identify variables that may elucidate the high mortality of patients with DNR orders. METHODS: Among a nationally representative sample of Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture, we retrospectively studied in-hospital and 180-day mortality and hospital lengths of stay for patients without DNR orders, with early (day 1 or 2) DNR orders, and with late (day 3 or later) DNR orders, before and after adjustment for sickness at hospital admission and patient and hospital characteristics. RESULTS: In-hospital mortality for patients with DNR orders exceeded that for patients without DNR orders before adjustment (59% vs 8%, P < .001), and after accounting for differences in sickness at admission and patient and hospital characteristics (40% vs 9%, P < .001). Sicker patients were assigned earlier DNR orders. Yet, patients with early DNR orders had a lower adjusted in-hospital mortality (31% vs 49%, P < .001) and shorter hospital stay (10 vs 18 days, P < .001) than did patients with late DNR orders. CONCLUSIONS: Hospitalized older patients with DNR orders have a much higher mortality than predicted by admission demographic and clinical characteristics. The differential association of early and late DNR orders with mortality indicates that DNR orders represent a heterogeneous group of interventions that may be a marker of unmeasured sickness and a determinant of quality of care. A better understanding of what the DNR order represents and its effect on patient care is needed to ensure optimal use.

Aged↗
PubMedDate not supplied

Impact of survival probability, life expectancy, quality of life and patient preferences on do-not-attempt-resuscitation orders in a hospital. Resuscitation Committee.

Consensus exists that a do-not-attempt-resuscitation order (DNAR) is appropriate if a resuscitation attempt is futile. Less agreement exists when this point is reached. We investigated the influence of three major considerations for in-hospital DNAR orders: expected survival probability after resuscitation, prospects of the patients' current condition without a cardiac arrest and the patients' autonomous decision not to want resuscitation. We calculated an expected survival probability according to two multi-morbidity prediction scores for each patient, assuming the event of cardiac arrest. The prospects of the current condition without a cardiac arrest was estimated by the patients' physician, in terms of life expectancy and quality of life (level of dependency after discharge and pain). The patients' preference was documented from the medical records. A total of 470 patients were included in the study. Fifty-eight patients (12%) had a DNAR-order, 11 of these patients (19%) wanted no resuscitation. The patients' prospects (life expectancy, dependency after discharge), and age proved to be independently associated with the presence of a DNAR order. The odds ratio (OR) for the presence of a DNAR order was 37 (CL 14-107) for an estimated life expectancy less than 3 months, 13 (CL 4-41) for a life in a nursing home and four (CL 2-12) for an age of 80 years and older. Expected survival probability after resuscitation and pain were not independently associated with a DNAR order. We conclude that resuscitation is considered futile on the basis of the patients' age and prospects without cardiac arrest and that the impact of expected survival probability on these decisions is small.

Aged↗
PubMed2003

[Do-not-resuscitate orders and cardiopulmonary resuscitation at a Norwegian department of surgery].

BACKGROUND: A previous publication indicates a lack of clear guidelines for DNAR orders in Norwegian hospitals. The Norwegian Board of Health has recently published strict requirements for such a procedure. MATERIAL AND METHODS: Patients discharged from a surgical department from 1 March to 31 May 2001 with complicated or advanced cancer and/or a postoperative stay of minimum ten days. The patient files were studied for information on DNAR orders and/or cardiac arrest. RESULTS: 13 out of 69 patients had a DNAR order. In eight of them there was either no explanatory note in the files or no correct signature. Three of the five other patients had taken part in the discussion, so had next-of-kin in two circumstances. Resuscitation was not initiated in any of 14 patients with cardiac arrest. Six of these, who had no DNAR order, all had advanced, inoperable cancer or serious chronic cardiac and respiratory failure. There were no signs that a DNAR order had influenced any other treatment decision. INTERPRETATION: The department had a clear procedure for writing DNAR orders but it was followed in less than half of the cases.

Cardiopulmonary Resuscitation↗
PubMedDate not supplied

Must consent always be obtained for a do-not-resuscitate order?

Using cardiopulmonary resuscitation for cardiac or respiratory arrest unless there is an explicit do-not-resuscitate order is a policy adopted by all hospitals. Such a policy usually requires the patient's (or surrogate's) consent for a do-not-resuscitate order to be instituted. This article, however, presents the argument that consent need not always be obtained. In the case discussed, the well-being of the patient, other patients, and the health care providers all support a unilateral decision by the physician not to attempt resuscitation at the time of death. The medical community and society need to acknowledge that such cases exist and to develop policies that respect not only the interests of patients but also those of health care providers and society.

Adult↗
PubMed1994

Practical guidelines for do-not-resuscitate orders.

Do-not-resuscitate orders are widely used, but discussions about their use too often take place late in the patient's illness, after the patient is no longer able to participate in the decision. Most patients have discussed resuscitation issues with their family and would like to have a similar discussion with their physician, but only 10 percent of patients have done so. Although few states have laws addressing the use of do-not-resuscitate orders, they are widely held to be legal based on existing legal precedent. To assist patients or their designated surrogate decision-makers, physicians should supply appropriate prognostic information: one-half of all patients survive resuscitation initially, one-third survive for 24 hours and one-eighth survive to leave the hospital. Certain medical conditions, such as metastatic cancer, impaired renal function, sepsis and dependent functional status are associated with a poor outcome. If conflict occurs, properly facilitated family meetings, repeated discussions and ethics committee consultations can be useful. Legal action should remain a last resort.

Advance Directives↗
PubMed1991

The do-not-resuscitate order. Ethical and legal imperative or medical decision?

Cardiopulmonary resuscitation (CPR), widely used in United States hospitals, results in long-term survival that averages about 15%. The patient has the ethical and legal right to reject CPR. Avoidance of CPR when death is anticipated, or when the patient does not wish resuscitation, requires the writing of a do-not-resuscitate order. Cardiopulmonary resuscitation has the risks of trauma, residual impairment if incompletely successful, and prolongation of dying. Like any other medical treatment, CPR should only be administered if it is expected to confer lasting benefit to the patient. If CPR does not offer even a modicum of lasting benefit, it is not medically appropriate to administer the treatment, and the physician may write a do-not-resuscitate order. The rationale for writing the order should be documented, and the patient and family should be informed of the treatment decision. Hospital regulations regarding the writing of DNR orders should reflect this approach. Experience to date indicates that there is minimal risk of malpractice or criminal action in relation to writing do-not-resuscitate orders.

Beneficence↗
PubMed1993

Do-not-resuscitate orders in a children's hospital.

OBJECTIVES: a) To quantify the use of do-not-resuscitate orders in a tertiary care children's hospital; and b) to characterize the circumstances in which such orders are written. DESIGN: Retrospective chart review. SETTING: University teaching hospital. PATIENTS: All inpatients who died in an urban children's hospital over a 1-yr period of time. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The hospital records of 54 of 69 patients who died were reviewed. Eighty-two percent of patient deaths occurred in the ICU; 13% of patient deaths occurred in the operating room, and 5% occurred in a medical ward. Other findings included the following: 25 (46%) of 54 patients died after attempted cardiopulmonary resuscitation; 13 (24%) patients were brain dead; and 16 (30%) died with a do-not-resuscitate order in effect. Age was associated with resuscitation status: do-not-resuscitate orders were written for five (21%) of 22 infants (< 1 yr of age); seven (50%) of 14 children (1 to 11 yrs of age); and four (80%) of five adolescents who died (p < .002). Fifteen of 16 do-not-resuscitate orders were written for patients who were in the ICU, where they remained until death. Findings in patients when the do-not-resuscitate orders were written were as follows: 15 ICU patients were receiving mechanical ventilation; 14 (95%) of 15 were receiving inotropic agents; 12 (80%) of 15 patients were receiving narcotic analgesics; and one (6%) patient was being dialyzed. At least one therapeutic modality was withdrawn in 7 (44%) of 16 patients. Do-not-resuscitate orders followed documented conferences with physicians and family members in 13 (81%) of 16 cases. These discussions were initiated by physicians in 12 (92%) of 13 cases. CONCLUSIONS: Do-not-resuscitate orders in pediatric patients are written more often in older than younger hospitalized children who die. Most do-not-resuscitate orders are written for patients who are receiving aggressive medical therapy in the ICU.

Age Factors↗
PubMed1997

An outcomes analysis of in-hospital cardiopulmonary resuscitation: the futility rationale for do not resuscitate orders.

PURPOSE: Cardiopulmonary resuscitation (CPR) is a frequently performed medical intervention in hospitalized patients who die. Despite the widespread use of do-not-resuscitate (DNR) orders during the last decade, the outcome following CPR appears not to have improved. The key to an improved outcome may be better patient selection. The objective of this study was to determine the hospital survival rate following CPR in the era of DNR orders, and to identify risk factors predictive of hospital survival at a university-affiliated teaching hospital. MATERIALS AND METHODS: We retrospectively reviewed the code sheets and patient charts of all patients who underwent CPR during a 4-year period from January 1991 to January 1995. Three-hundred-and-eight patients were identified. RESULTS: CPR was successful in 99 (32%) patients, with 41 (13%) patients surviving to hospital discharge. All the patients who survived were otherwise "healthy" with reversible conditions, who experienced a sudden and unexpected arrhythmic event. No pre-arrest risk factors could clearly distinguish the hospital survivors from the nonsurvivors. The length of the code was 9.4 +/- 4 minutes in the hospital survivors compared with 26.6 +/- 19.1 minutes in the nonsurvivors. Patients whose initial rhythm was either ventricular tachycardia or fibrillation had a better survival rate than patients with other rhythms. CONCLUSION: DNR protocols do not prevent CPR being performed on patients who are unlikely to survive to hospital discharge. CPR should only be offered to patients who are likely to derive benefit from this intervention.

Adolescent↗
PubMed1998

Perceptions of do-not-resuscitate orders.

Do-not-resuscitate (DNR) orders have differing meanings for persons depending on their age, training, and personal beliefs. In this paper we explore these meanings as expressed in the attitudes about do-not-resuscitate orders of three groups: university students in a health-related discipline of social work, university students in a non-health related discipline, and persons over the age of sixty. Findings from analysis of the three groups suggest a strong interest in issues surrounding resuscitation. Social and nonmedical factors are important in the decision to resuscitate and therefore should be given careful consideration. Next to their spouse, respondents named their physician as the person they most wanted to talk with about withholding resuscitation. Yet, studies of physicians cited earlier indicate many physicians are hesitant to discuss end of life decisions with their patients. With the added help and support of the family, concerned friends, and social workers, individuals can make the best possible DNR decision and avoid unnecessary pain and suffering.

Adult↗
PubMed1997

The impact of do-not-resuscitate orders on nursing workload in an ICU.

BACKGROUND: The meaning of do-not-resuscitate orders and their impact on nursing care have been a source of confusion, and the results of the few studies that have examined nursing care of ICU patients with these orders have been conflicting. OBJECTIVES: To assess nursing workload associated with caring for patients with do-not-resuscitate orders and to better understand the patients and selected events associated with these orders. METHOD: Sixty patients from medical, surgical, and neuroscience ICUs met the criteria for the study. The Medicus Systems Corporation InterAct 2000 Workload and Productivity System was used to classify patients by type; the results reflected the number of hours of nursing care required per 24 hours. Data on patient type for 1 day before and 1 day after do-not-resuscitate orders were written were available for 31 of the 60 patients. These data were analyzed. RESULTS: The number of hours of nursing care required 1 day before and 1 day after a do-not-resuscitate order did not change. The amount of nursing care remained the same or increased for 74% (23/31) of the patients after the order was written. Patients were classified as types IV (n = 8), V (n = 20), and VI (n = 3) after the order was written. CONCLUSIONS: A high level of nursing care was required for this group of critically ill patients, and the do-not-resuscitate order did not alter the number of hours of nursing care required after the order was written.

APACHE↗
PubMed2003

Should do-not-resuscitate orders be suspended for surgical cases?

PURPOSE OF REVIEW: There are significant misunderstandings about the management of perioperative do-not-resuscitate orders. This paper reviews some of the difficulties generated by the halting acceptance and inconsistent implementation of an ethically appropriate perioperative do-not-resuscitate policy that mandates reconsideration of existing do-not-resuscitate orders. It also offers strategies for empowerment of such a policy. RECENT FINDINGS: Recent advances in the ethical practice of anesthesiology have centered on determining and correcting why perioperative do-not-resuscitate policies are poorly accepted, and how to establish a hospital-wide adherence to such policies. Barriers to ethically appropriate application of perioperative do-not-resuscitate orders include differing values and misunderstandings between physicians and their patients - and also between anesthesiologists and other physicians - as well as medicolegal concerns. Policies should be designed and implemented at the level of the healthcare institution, and they must be sufficiently flexible to permit the tailoring of the perioperative do-not-resuscitate order to the autonomous choice of the patient. Such policies should state unambiguously that existing do-not-resuscitate orders are to be reevaluated, delineate responsibilities for reconsidering the do-not-resuscitate order, state available options, define necessary documentation, and list resources for help. SUMMARY: A well written perioperative do-not-resuscitate policy is essential for surmounting obstacles to a well functioning perioperative do-not-resuscitate system.

Journal Article↗
PubMed1994

Effect of do-not-resuscitate orders on the nursing care of critically ill patients.

BACKGROUND: The effect of a do-not-resuscitate order on the standard of care of critically ill patients is of concern to practitioners, patients, and their families. Because "do not resuscitate" may be misconstrued to include more than "no cardiopulmonary resuscitation," it may influence the aggressiveness with which some patients are managed. Nurses play a central role in determining standards of care. Hence, confusion on their part as to the meaning of this term can have a significant impact on patient care. OBJECTIVES: To compare nurses' attitudes about standards of care for critically ill patients with and without a do-not-resuscitate order. METHOD: A quasi-experimental design using simulation measurement was used for this study. RESULTS: Nurses reported that they would be significantly less likely to perform a variety of physiologic monitoring modalities and interventions for patients with a do-not-resuscitate order than for patients without such an order. Patients with a do-not-resuscitate order were more likely to receive psychosocial interventions including assessment of their spiritual needs and more flexible visiting practices. CONCLUSIONS: Our findings suggest that "do-not-resuscitate" may be misinterpreted to include more than "no cardiopulmonary resuscitation" even if the patient is receiving aggressive medical management. Misinterpretation of orders not to resuscitate may be related to a variety of factors including lack of understanding about hospital policy and ethical and moral values of the staff. We suggest replacing orders such as "Do not resuscitate" with clearly defined resuscitation plans that are jointly determined by the multidisciplinary team, patient, and family.

Adult↗
PubMed1990

The do-not-resuscitate order. Still too little too late.

We reviewed the records of 274 consecutive deaths at the Milton S. Hershey Medical Center, Hershey, Pa, occurring through May 1988 to examine the approach of physicians, patients, and families in making the decision to invoke the "do-not-resuscitate" order. Of these 274 patients who died, 171 (62%) had do-not-resuscitate orders. Of these 171 patients, 86 (50%) were judged fully mentally competent on admission to the hospital; 44 (51%) of these 86 fully competent patients were included in the decision to withhold resuscitative efforts. In the remainder, the family was usually involved in the decision without input from the patient. Only 6 patients (4%) were admitted to the hospital with a preexisting do-not-resuscitate order. For the remainder, the do-not-resuscitate order was written a mean of 8.5 days following admission and 3.3 days before death. Documentation of this order with a specific progress note was universal. The principle reason cited for a do-not-resuscitate order was the presence of irreversible terminal disease in 52% and an unacceptable quality of life in 33%. When considered separately, patients with a principle diagnosis of malignant neoplasm had a do-not-resuscitate order written 80% of the time. Of 88 such patients, 48 (55%) were fully competent at admission. In turn, 36 (75%) of these patients participated in the do-not-resuscitate decision. Nursing activities were quantified for the 24 hours preceding and the 24 hours following the do-not-resuscitate order. No difference could be found comparing these two periods whether the comparison was made on the general hospital ward or in the intensive care unit.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1984

Do-not-resuscitate orders in a county hospital.

The use of the do-not-resuscitate order has become accepted medical practice. To date, however, no study has been done of how often it is used or factors associated with its use. Reports of all deaths of inpatients occurring during calendar year 1981 at San Bernardino County Medical Center were eligible for study. Retrospective review of the 237 cases indicated that a do-not-resuscitate order had been written for 165 (69.6%) of the patients. Comparison of reports of those for whom such an order had been written with those for whom no order had been written indicated that a do-not-resuscitate order was not associated with age, sex, ethnicity or pay status. Indices of mental clarity, however, were associated with orders not to resuscitate; those patients residing in nursing homes, and not alert and oriented on admission were overrepresented in the group given this order. Primary discharge diagnosis was also associated with such an order, as was an increased duration of hospital stay.

California↗
PubMed2003

Hospitalisation, care plans and not for resuscitation orders in older people in the last year of life.

BACKGROUND: over 60% of older people have at least one admission to hospital in their last year of life, with the majority of people having multiple admissions. In Bankstown, New South Wales, Australia, we have a diverse ethnic and cultural population. We were interested in bed utilisation, documentation, and follow through of "care plans" as well as "not for resuscitation" orders in the last year of life of the older people in our area. METHODS: we reviewed and collected data from the medical records of patients over 65 years of age who died in our hospital. Reviewers included a medical registrar, a research officer and two geriatricians. We collected a wide range of information pertaining to the 12 months before death. This included demographics, chronic illnesses, geriatric syndromes, number of admissions, bed days, care plans, and not for resuscitation orders as well as other relevant data. RESULTS: 110 patients' records were reviewed. The mean age was 80 years and 31% were from a non English-speaking background. The average number of admissions was 2.4 and the average number of bed days in the last year of life was 25. Sixty-one of the patients had a care plan and a not for resuscitation order, 91% of which were written shortly before death. Using bi-variate analysis of old age (over 80), number of chronic illnesses, or geriatric syndromes present, the number of bed days was positively correlated to care plan and not for resuscitation orders. Logistic multivariate analysis of chronic illnesses revealed that stroke (P=0.024) as well as stroke and fracture (P=0.008) were strongly correlated with care plan and not for resuscitation orders. Only 8 patients had an advanced care plan documented prior to last admission. When advanced care plans were documented, they were generally clearly written and followed through appropriately (7 out of 8). CONCLUSION: this study showed that in our diverse population there were multiple admissions and utilisation of hospital beds for older people in their last year of life. Care plans and not for resuscitation orders were rarely documented prior to last admission. However, when advanced care plans were done, they were usually well documented and followed through appropriately.

Aged↗