Abstract
Objective
To determine the accuracy of do-not-resuscitate/do-not-intubate (DNR/DNI) orders in
representing patient preferences regarding cardiopulmonary resuscitation (CPR) and
intubation.
Patients and Methods
We conducted a prospective survey study of patients with documented DNR/DNI code status
at an urban academic tertiary care center that serves approximately 250,000 patients
per year. From October 1, 2010, to October 1, 2011, research staff enrolled a convenience
sample of patients from the inpatient medical service, providing them with a series
of emergency scenarios for which they related their treatment preference. We used
the Kendall τ rank correlation coefficient to examine correlation between degree of
illness reversibility and willingness to be resuscitated. Using bivariate statistical
analysis and multivariate logistic regression analysis, we examined predictors of
discrepancies between code status and patient preferences. Our main outcome measure
was the percentage of patients with DNR/DNI orders wanting CPR and/or intubation in
each scenario. We hypothesized that patients with DNR/DNI orders would frequently
want CPR and/or intubation.
Results
We enrolled 100 patients (mean ± SD age, 78±13.7 years). A total of 58% (95% CI, 48%-67%)
wanted intubation for angioedema, 28% (95% CI, 20%-3.07%) wanted intubation for severe
pneumonia, and 20% (95% CI, 13%-29%) wanted a trial resuscitation for cardiac arrest.
The desire for intubation decreased as potential reversibility of the acute disease
process decreased (Kendall τ correlation coefficient, 0.45; P<.0002).
Conclusion
Most patients with DNR/DNI orders want CPR and/or intubation in hypothetical clinical
scenarios, directly conflicting with their documented DNR/DNI status. Further research
is needed to better understand the discrepancy and limitations of DNR/DNI orders.
Abbreviations and Acronyms:
AD (advance directive), CPR (cardiopulmonary resuscitation), DNI (do-not-intubate), DNR (do-not-resuscitate), MOLST (medical orders for life-sustaining therapy), POLST (physician orders for life-sustaining therapy)To read this article in full you will need to make a payment
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References
- Defining features of advance directives in law and clinical practice.Chest. 2012; 141: 232-238
- The accuracy of surrogate decision makers: a systematic review.Arch Intern Med. 2006; 166: 493-497
- Myth of substituted judgment: surrogate decision making regarding life support is unreliable.Arch Intern Med. 1994; 154: 90-96
- Controlling death: the false promise of advance directives.Ann Intern Med. 2007; 147: 51-57
- How strictly do dialysis patients want their advance directives followed?.JAMA. 1992; 267: 59-63
- Patient, physician, and family member understanding of living wills.Am J Respir Crit Care Med. 2002; 166: 1430-1435
- Patients' knowledge of options at the end of life: ignorance in the face of death.JAMA. 2000; 284: 2483-2488
- Understanding the treatment preferences of seriously ill patients.N Engl J Med. 2002; 346: 1061-1066
- The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.N Engl J Med. 1994; 330: 545-549
- Cardiopulmonary resuscitation on television: miracles and misinformation.N Engl J Med. 1996; 334: 1578-1582
- Accuracy of predictions of survival at admission to the intensive care unit.J Crit Care. 2001; 16: 32-35
- Advance directives in the emergency department: too few, too late.Acad Emerg Med. 1996; 3: 50-53
- Code status discussions between attending hospitalist physicians and medical patients at hospital admission.J Gen Intern Med. 2011; 26: 359-366
- Do-not-resuscitate orders in evolution: matching medical interventions with patient goals.Crit Care Med. 2011; 39: 1213-1214
- Limitations of listing specific medical interventions in advance directives.JAMA. 1991; 266: 825-828
- Increasing use of DNR orders in the elderly worldwide: whose choice is it?.J Med Ethics. 2002; 28: 303-307
- Current end-of-life care needs and care practices in acute care hospitals.Nurs Res Pract. 2011; 2011: 869302
- End-of-life decision making in intensive care.Crit Care Nurse. 2005; 25: 28-38
- Elderly persons' last six months of life: findings from the hospitalized elderly longitudinal project.J Am Geriatr Soc. 2000; 48: S131-S139
- Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003.Ann Emerg Med. 2008; 51: 769-774
- Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.Ann Intern Med. 1999; 131: 721-728
- Ethical challenges of partial do-not-resuscitate (DNR) orders: placing DNR orders in the context of a life-threatening conditions care plan.Arch Intern Med. 2003; 163: 2270-2275
- Do-not-resuscitate orders, unintended consequences, and the ripple effect.Crit Care. 2007; 11: 121
- Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure.Am Heart J. 2008; 156: 78-84
- Ethical issues of cardiopulmonary resuscitation: comparison of emergency physician practices from 1995 to 2007.Acad Emerg Med. 2009; 16: 270-273
- Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT.J Am Geriatr Soc. 2000; 48: S176-S182
- Partial do-not-resuscitate orders: a hazard to patient safety and clinical outcomes?.Crit Care Med. 2011; 39: 14-18
- Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections.J Am Geriatr Soc. 2004; 52: 51-58
- Do-not-resuscitate orders in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study.Arch Intern Med. 2004; 164: 776-783
- A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program.J Am Geriatr Soc. 2010; 58: 1241-1248
- The POLST (physician orders for life-sustaining treatment) paradigm to improve end-of-life care: potential state legal barriers to implementation.J Law Med Ethics. 2008; 36: 119-140
- Use of the physician orders for life-sustaining treatment program in Oregon nursing facilities: beyond resuscitation status.J Am Geriatr Soc. 2004; 52: 1424-1429
- Use of the physician orders for life-sustaining treatment (POLST) paradigm program in the hospice setting.J Palliat Med. 2009; 12: 133-141
- Lost in translation: the unintended consequences of advance directive law on clinical care.Ann Intern Med. 2011; 154: 121-128
- Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.J Gen Intern Med. 2008; 23: 1877-1882
Article Info
Footnotes
For editorial comment, see page 641.
Identification
Copyright
© 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
