The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act

E D Morrell, B P Brown, R Qi, K Drabiak, P R Helft
2008 Journal of Medical Ethics  
Since the passage of the Patient Self-Determination Act, numerous policy mandates and institutional measures have been implemented. It is unknown to what extent those measures have affected end-of-life care, particularly with regard to the do-notresuscitate (DNR) order. Methods: Retrospective cohort study to assess associations of the frequency and timing of DNR orders with advance directive status, patient demographics, physician's specialty and extent of documentation of discussion on
more » ... ife care. Results: DNR orders were more frequent for patients on a medical service than on a surgical service (77.34% vs 64.20%, p = 0.02) and were made earlier in the hospital stay for medicine than for surgical patients (adjusted mean ratio of time from DNR orders to death versus total length of stay 0.30 for internists vs 0.21 for surgeons, p = 0.04). 22.18% of all patients had some form of an advance directive in their chart, yet this variable had no impact on the frequency or timing of DNR ordering. Documentation of DNR discussion was significantly associated with the frequency of DNR orders and the time from DNR to death (2.1 days with no or minimal discussion vs 2.8 days with extensive discussion, p,0.01). Conclusions: The physician's specialty continues to have a significant impact on the frequency and timing of DNR orders, while advance directive status still has no measurable impact. Additionally, documentation of endof-life discussions is significantly associated with varying DNR ordering rates and timing. The do-not-resuscitate (DNR) order was introduced as a way to provide competent patients the chance to express their actions regarding their right to refuse treatment. 1-3 However, numerous studies conducted in the USA during the late 1980s and early 1990s found that factors such as the patient's age, 4-8 diagnosis 4 6-12 and sex, 6 in addition to the physician's specialty, 13 the medical institution 8 and the hospital unit, 6 were all significantly associated with variable patterns of DNR ordering. Perhaps most importantly, the majority of those studies showed that patients were infrequently involved in DNR decisions, 4-6 9-11 13-15 in some cases even when they were judged mentally competent. 9 In response to these findings and what was then a growing perception in the healthcare community that there were substantial ethical shortcomings in end-of-life care, the Patient Self-Determination Act (PSDA) was passed in 1991. This US federal law required that healthcare institutions receiving any type of federal funding inform their patients about their medical decision-making rights, including the right to refuse life-sustaining care such as cardiopulmonary resuscitation. 16 After the passage of the PSDA, data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) conducted from 1989 to 1994 revealed that patient involvement in DNR orders (including the influence of advance directives) was still limited and that physicianrelated factors were still highly influential in endof-life care. [17] [18] [19] [20] [21] Have the patterns of DNR order writing changed in hospitalised patients 15 years after the passage of the PSDA? In order to address this question, we carried out a retrospective cohort study of patients who were hospitalised and died in one Midwestern US academic hospital in a single calendar year to directly compare the influence of patient-, physician-, and system-specific factors on patterns of DNR ordering. Here we report our results and compare them with findings from studies conducted around the time of the passage of the PSDA and the SUPPORT trial. METHODS Data collection We conducted a retrospective chart review of all patients who died in 2005 at Indiana University Hospital, a 390-bed, tertiary-care hospital in downtown Indianapolis, Indiana. Initial information regarding the age, sex, race, diagnosis-related group (DRG) diagnosis, cause of death and discharging (primary) service was collected for all patients by accessing the billing records for the calendar year 2005. Secondary patient information was collected through retrospective chart review. Each medical chart was reviewed by one of the authors and information was collected using a data collection sheet of the authors' design. Each patient's length of stay was recorded. We also recorded the number of days between entry of an official DNR order in the patient's chart and the patient's death. Because the range of lengths of stay was so large, we controlled for length of stay by examining the timing of DNR orders as a ratio of the time between DNR order entry and death to overall length of stay. Secondary information collected from each chart included the presence of a written Clinical ethics 642
doi:10.1136/jme.2007.022517 pmid:18757631 fatcat:xwff67jwsnfg3dmxrfwxomzx2i