To describe current "do not resuscitate" (DNR) order writing practices, we studied 7,265 intensive care unit (ICU) admissions at 13 hospitals. All of the ICUs used DNR orders and 39% of all in-unit deaths were preceded by them. Patients with DNR orders were often elderly and in severely failing health. They were more severely ill than other patients in ICUs, and often had multiple organ failure. Most patients with DNR orders (94%) died in the hospital, and 86% died or were discharged from the ICU three days after a DNR order. The frequency of DNR orders ranged from 0.4% to 13.5%, and the mean interval from ICU admission to DNR order was from 5.4 to 24 days. These variations could not be explained by differences in patient characteristics, and may reflect varying physician attitudes. Do not resuscitate orders are now an accepted practice in ICUs and their use follows basic ethical and scientific guidelines. The brief interval between writing a DNR order and death or ICU discharge suggests that they often represent a decision point for placing broader limits on therapy.
KIE: Researchers at the George Washington University Medical Center (GWUMC) studied "do not resuscitate" (DNR) practices in the intensive care units of 13 hospitals covering 7,265 admissions. Variations found in the use and timing of DNR orders were attributed to physician treatment decisions rather than to patient presentation. DNR decisions were frequently accompanied by withdrawal of other life-support therapy. Information collected at GWUMC supported the contention that the physician is dominant in the DNR decision, that families do participate in the discussion, but that patient participation is low--frequently due to reduced consciousness. The authors conclude that physician recognition of the limits of aggressive medical care is compatible with the ethical values of not prolonging death unnecessarily, avoiding treatment that does not positively affect the patient's condition, and distributing medical resources to patients who are most likely to benefit.