The use and implications of do not resuscitate orders in intensive care units

J. E. Zimmerman, W. A. Knaus, S. M. Sharpe, A. S. Anderson, E. A. Draper and D. P. Wagner

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.

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