Regional and Institutional Variation in the Initiation of Early Do-Not-Resuscitate Orders

Zingmond, David S.; Wenger, Neil S.

doi:10.1001/archinte.165.15.1705

Cited by 69 publications

(68 citation statements)

References 29 publications

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“…Zingmond et al showed that use of early DNR orders in patients admitted with 40 of the most common medical and surgical diagnosis-related groups (DRGs) was affected by hospital size and geographic location, even after accounting for patient characteristics. 9 Among patient characteristics, previous studies showed that being older, White, and having more medical comorbidities increases the likelihood of having a DNR order across multiple medical conditions. [7][8][9] Using a nationally representative sample of nearly 14,000 Medicare patients, Wenger and colleagues showed that the frequency and the factors that influence DNR use also varied significantly by medical diagnoses.…”

Section: Discussionmentioning

confidence: 99%

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Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

Chang

Brass

2014

J GEN INTERN MED

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BACKGROUND: Identifying factors associated with donot-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed. METHODS: A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders. RESULTS: Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order. CONCLUSION: Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .KEY WORDS: end-of-life care; healthcare delivery; epidemiology.

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Section: Discussionmentioning

confidence: 99%

“…[6][7][8][9] Because administrative data typically captures only those DNR orders placed in the first 24 h of hospitalization, most studies have only examined factors that are associated with early DNR orders. However, the factors that influence the likelihood of a DNR order later in the hospital course may be different.…”

Section: Introductionmentioning

confidence: 99%

Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

Chang

Brass

2014

J GEN INTERN MED

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“…17,18,25 Larger institutions, academic centers, and hospitals in urban areas have lower rates of DNR orders compared with smaller, nonacademic, and rural hospitals. 45 While the lower rates of DNR orders may reflect the preferences of self-selected patients to a certain extent, another likely contributing factor is the providers' bias towards proceeding with treatments rather than engaging in discussions about goals of care and setting limits to further interventions.…”

Section: Reasons For Inadequate Dnr Discussion and Recommended Stratmentioning

confidence: 99%

“…Under this payment model, it is not surprising that for-profit hospitals that are associated with more costly and greater intensity of care also have lower rates of early DNR orders. 45 To change institutional practices to increase the incidence and improve the timeliness of code status discussions, the incentives system will need to be better aligned to motivate hospitals and providers to provide care that is patient-centered.…”

Section: Text Box 2 Proposed Joint Commission Standards For Dnr Discmentioning

confidence: 99%

Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them

2011

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Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes-to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient selfdetermination and avoiding non-beneficial interventions at the end of life.KEY WORDS: do-not-resuscitate orders; informed consent; end-of-life care.

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“…While patient prognosis and quality of life have been identified as factors that influence decision‐making on DNAR orders,6, 7, 8, 9 it is not always feasible to expect a favorable outcome for patients with malignant tumors or pneumonia, or in patients who are elderly or senile, and this poor prognosis can lead to a DNAR order. However, even if a patient has a poor prognosis, it does not always mean that he/she does not wish to be resuscitated or receive aggressive treatment.…”

Section: Discussionmentioning

confidence: 99%

Do not attempt resuscitation order in Japan

Inokuchi

Kobayashi

Ohkubo

2017

Acute Medicine & Surgery

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AimIn Japan, the do not attempt resuscitation (DNAR) order is practised routinely even though no related laws or guidelines exist. This study aimed to clarify the current status of DNAR, reveal existing DNAR‐related issues, and improve the application of DNAR.MethodsA questionnaire survey of medical institutions in Kanagawa Prefecture (total population, 9,120,000) about the current status of DNAR was carried out.ResultsThe results showed that DNAR has been practised at approximately 90% of the hospitals surveyed, but only about 30% have developed in‐hospital DNAR guidelines. Approximately 80% of the hospitals do not involve patients in the decision on their own DNAR orders. Because the DNAR order has not been legislated, it is often unclear whether to resuscitate patients when a request for an ambulance is made for a cardiac arrest at home.ConclusionIt is necessary for prefectures, municipalities, and local medical control authorities to take the initiative in establishing an ordinance on DNAR orders and developing guidelines.

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Regional and Institutional Variation in the Initiation of Early Do-Not-Resuscitate Orders

Cited by 69 publications

References 29 publications

Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them

Do not attempt resuscitation order in Japan

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