The Choice Not To Be Resuscitated

Abstract

We studied the use of the do not resuscitate (DNR) order among general medical patients. During the six-month study period, of 2431 admissions there were 95 patients (3.9%) declared DNR. Of 105 deaths, 69 (66%) occurred among DNR patients. Twenty-seven percent of the DNR patients left the hospital alive. In 90% of the cases the medical intern initiated the DNR discussion, and in 60% of the cases a decision was reached in less than 24 hours. Two-thirds of the DNR orders were consented to by family members, and one-third of all DNR orders had a discernible impact on nonresuscitative care. Less aggressive therapy accounted for 60% of these restrictions, whereas the remainder involved limitations in diagnostic evaluations. When compared with age- and sex-matched general adult inpatient control subjects, DNR patients were found to have longer hospitalizations (P = .01), be more likely to reside in a nursing home (RR = 4.2), have a metastatic neoplasm (RR = 3.6), and be admitted with an abnormal mental status (RR = 6.1) or urinary incontinence (RR = 2.9). These differences remained significant when we controlled for the presence of a metastatic neoplasm. Despite a high in-hospital mortality rate (73%), DNR patients were not admitted more frequently than controls to the intensive care unit. We conclude that the DNR decision is based on clinical prognostic indexes and that once established, this order serves to modify the allocation of medical resources.

Deciding not to resuscitate in Dutch hospitals.

“…The percentage of deaths preceded by a DNR decision is reported to be 62 per cent-70 per cent in the United States (13,14,(16)(17)(18). This coincides with our figure (61 per cent).…”

“…The percentage of admissions in which a DNR decision is made (6 per cent), is higher than that given by American studies: it is usually reported that a DNR decision is made for 3-4 per cent of all hospitalized patients (10)(11)(12)(13)(14), with the exception of Evans who reports 9 per cent (15). As stated, data from two different countries with different healthcare systems and different mores may not be fully comparable.…”

Female Gender Remains an Independent Risk Factor for Poor Outcome after Acute Nontraumatic Intracerebral Hemorrhage

“…Higher inflammatory response in hemorrhagic stroke has been associated with poor outcomes [17, 18]; studies have reported that females tend to have more robust inflammatory response in some diseases [19]. This could have led to poor outcome in females, although we were not able to capture data regarding inflammatory measures such as midline shift, perihematomal edema, or herniation.…”

Evaluation of end of life care in cancer patients at a teaching hospital in Japan

“…23 In general, patients in Japanese hospitals participated in the decision about their own DNR orders for themselves at a lower rate (5%) than patients in other countries (14-41%). [24][25][26][27][28] Patients in Japan have traditionally tended to entrust their most important treatment decisions to physicians. However, the absence of patient's DNR consent raises the question of whether the attending resident or staff physician decisions fundamentally reflect wishes and opinions of the patient.…”