Chest
Volume 110, Issue 5, November 1996, Pages 1332-1339
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Ethics in Cardiopulmonary Medicine
Variations in the Use of Do-Not-Resuscitate Orders in ICUs: Findings From a National Study

https://doi.org/10.1378/chest.110.5.1332Get rights and content

Study objectives

To describe the variation in frequency of do-not-resuscitate (DNR) orders in 42 US ICUs and to examine the relationship between published guidelines and qualitative observations about terminal care in 9 ICUs.

Design

Prospective inception cohort.

Setting

Forty-two ICUs in 40 US hospitals with more than 200 beds: 26 randomly selected and 14 large tertiary-care volunteers.

Participants

A consecutive sample of 17, 440 ICU admissions during 1988 to 1990.

Measurements and results

We used age, race, comorbid conditions, disease, functional status, and acute physiology score on ICU day 1 to predict the likelihood of a DNR order for each patient. A cross-validated model was then used to predict variations in the risk of an ICU DNR order from 0 to 45% (area under receiver operating characteristic curve=0.9). The model was then used to compare aggregate observed with predicted frequency of ICU DNR orders. Finally, we compared observations of DNR practices by a team of clinical and organizational researchers at 9 of the 42 ICUs with published guidelines and risk-adjusted DNR frequency: 1, 577 admissions (9%) had DNR orders written in the ICU (range, 1.5 to 22%). The ICU site was a significant (p<0.0001) predictor of variance in the patient level model. DNR orders were written significantly (p<0.05) less frequently than predicted in 5 and more frequently than predicted in 3 of 42 ICUs. Nonwhite patients had significantly (p=0.0001) fewer DNR orders after adjustment. The research team's implicit judgments following on-site analysis failed to distinguish ICUs with more or less DNR orders than predicted. Site-visited ICUs exhibited practices to emulate and practices to avoid.

Conclusions

The frequency of ICU DNR orders can be predicted based on individual risk factors for groups of ICU patients. After adjusting for differences in patient characteristics, there is significant variation in the frequency of DNR orders in a national sample of ICUs. These variations may be due to unmeasured differences in patient characteristics such as treatment preferences, religious affiliation, educational level, or physician practices. We found no relationship between risk-adjusted DNR order frequency and adherence to published guidelines.

Section snippets

Hospital Selection

As part of the APACHE III study, we collected information from 42 ICUs at 40 hospitals. To represent ICU care in nonfederal US hospitals with more than 200 beds, we selected 26 hospitals using stratified random criteria based on number of beds, region, and teaching status. Fourteen nonrandomized hospitals, primarily university or tertiary care hospitals with an interest in the study, volunteered to participate. We collected data in 2 separate medical and surgical ICUs at 2 volunteer hospitals

RESULTS

We collected information for 17, 440 ICU admissions to 42 ICUs at 40 hospitals, including 818 patients who were readmitted to the ICU during their hospital stay. Data were available for an average of 415 (range, 299 to 499) unselected admissions to each ICU during an average period of 9.7 months (range 3–17 months). DNR orders were written in the ICU for 1, 577 (9%) of these admissions. For the 16, 662 who were not ICU readmissions, 1, 441 (8.7%) had DNR orders written; 1, 156 (6.9%) during the

DISCUSSION

The 42 ICUs in our study had observed DNR order rates during the first 7 days of ICU care that varied from 0.9 to 16.7% of ICU admissions over an average of 9.7 months. Much of this variation (49%, R2=0.49) across ICUs was due to clinically relevant patient characteristics. The most important factors associated with a DNR order are the patient's severity of physiologic abnormalities, age, admission diagnosis, and prior health status (Fig 1). These factors have been associated previously with

ACKNOWLEDGMENTS

We wish to acknowledge Stephen M. Shortell, PhD, Denise M. Rousseau, PhD, Robin R. Gillies, PhD, Kelly J. Devers, MD, and Joanne Duffy, DNSc, for their contributions to the nine ICU on-site analyses, and Beth C. Horowitz, MD, for help in editing the manuscript.

REFERENCES (54)

  • RogersWH et al.

    Quality of care before and after implementation of the DRG-based prospective payment system: a summary of effects

    JAMA

    (1990)
  • Withholding and withdrawing life-sustaining therapy

    Ann Intern Med

    (1991)
  • Guideline for appropriate use of do-not-resuscitate orders

    JAMA

    (1991)
  • The New York State Task Force on Life and the Law

    (1987)
  • WaiselDB et al.

    The cardiopulmonary resuscitation-not-indicated order: futility revisited

    Ann Intern Med

    (1995)
  • (1990)
  • O'TooleEE et al.

    Evaluation of a treatment limitation policy with a specific treatment limiting order page

    Arch Intern Med

    (1994)
  • StemSG et al.

    DNR or CPR—the choice is ours

    Crit Care Med

    (1992)
  • MaksoudA et al.

    Do not resuscitate orders and the cost of death

    Arch Intern Med

    (1993)
  • BlackhallLJ et al.

    Discussions regarding aggressive care with critically ill patients

    J Gen Intern Med

    (1989)
  • YoungnerSJ et al.

    ‘Do not resuscitate' orders: incidence and implications in a medicalintensive care unit

    JAMA

    (1985)
  • KaneRL et al.

    Assessing the outcomes of nursing-home patients

    J Gerontol

    (1983)
  • ZimmermanJE

    The APACHE III study design: analytic plan for evaluation of severity and outcome

    Crit Care Med

    (1989)
  • ZimmermanJE et al.

    Intensive care at two teaching hospitals: an organizational case study

    Am J Crit Care

    (1994)
  • ZimmermanJE et al.

    Improving intensive care: observations based on organizational case studies in nine intensive care units: a prospective, multicenter study

    Crit Care Med

    (1993)
  • KnausWA et al.

    APACHE II: a severity of disease classification system

    Crit Care Med

    (1985)
  • KochKA et al.

    Changing patterns of terminal care management in an intensive care unit

    Crit Care Med

    (1994)
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    Supported by the Agency for Health Care Policy and Research (HSO 5787), The John A. Hartford Foundation (87267), The Department of Anesthesiology, George Washington University Medical Center, and APACHE Medical Systems Inc.

    All the authors certify that affiliations with or involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in this article are disclosed as follows: Drs. Knaus, Zimmerman, and Wagner are founders and minority equity shareholders of APACHE Medical Systems, Inc, a for-profit Delaware-based corporation that funded, in part, the research for the APACHE III® study. APACHE Medical Systems markets a software-based clinical information system based on some of the concepts described in this article. Drs. Knaus, Zimmerman, and Wagner receive financial support in the form of research grants from APACHE Medical Systems.

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