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Do-Not-Resuscitate Orders in Intensive Care UnitsCurrent Practices and Recent Changes
Robert L. Jayes, MD;
Jack E. Zimmerman, MD;
Douglas P. Wagner, PhD;
Elizabeth A. Draper, MS, RN;
William A. Knaus, MD;
Bart Chernow, MD;
David Dantzker, MD;
Jerrold Leiken, MD;
Joseph E. Parrillo, MD;
William J. Sibbald, MD;
Jean-Louis Vincent, MD, PhD
JAMA. 1993;270(18):2213-2217.
Abstract
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Objectives.
—To describe the characteristics of patients with do-not-resuscitate (DNR) orders and the frequency and timing of these orders in a representative sample of intensive care units (ICUs) and to compare practices from 1980 to 1990.
Design.
—Prospective inception cohort.
Setting.
—A total of 42 ICUs in 40 US hospitals with 200 or more beds; 26 randomly selected hospitals and 14 large, tertiary care hospitals that volunteered to be studied.
Participants.
—A consecutive sample of 17440 ICU admissions from 1988 to 1990.
Measurements.
—Patient demographic characteristics, comorbid conditions, disease, and physiological abnormalities.
Main Outcome Measures.
—Frequency and timing of DNR orders; ICU resource use before and after DNR orders; and patients' hospital and ICU discharge status.
Results.
—Physicians wrote DNR orders for 1577 ICU admissions (9%) (hospital range, 1.5% to 22%). Patients with ICU DNR orders were older, more functionally impaired, had more comorbid illness, a higher severity of illness, and required the use of more ICU resources compared with patients without DNR orders. Compared with data from a similar survey from 1979 to 1982, ICU DNR orders were more frequent in 1988 to 1990 (9% vs 5.4%; P<.001) and preceded 60% of all in-unit deaths compared with only 39% in 1979 to 1982 (P<.001). Do-not-resuscitate orders were written sooner (for 3.6% vs 2.0% of patients on day 1 in the ICU) and patients with DNR orders remained in the ICU longer in 1988 to 1990 (2.8 vs 1.4 days) than in 1979 to 1982, and had lower ICU and hospital mortality rates (64% vs 74%, P<.001; and 85% vs 94%, P<.001).
Conclusions.
—Over the last decade physicians and patients' families set limits earlier and more frequently in cases likely to have poor outcomes. We attribute this change to a greater dialogue about setting limits to care and a greater knowledge of treatment outcomes among physicians and families. These changes in practice preceded implementation of the Patient Self-determination Act, designed to ensure patient autonomy for decisions about life-sustaining therapy.
(JAMA. 1993;270:2213-2217)
Author Affiliations
Baltimore, Md; New Hyde Park, NY; Chicago, Ill; Chicago, Ill; London, Ontario; Brussels, Belgium.
From the Departments of Medicine (Drs Jayes and Zimmerman) and Anesthesiology (Dr Zimmerman) and the ICU Research Unit (Drs Wagner and Knaus), George Washington University Medical Center, Washington, DC; and APACHE Medical Systems Inc, Washington, DC (Ms Draper).
Footnotes
Drs Knaus, Zimmerman, and Wagner are founders and shareholders of APACHE Medical Systems Inc (AMS Inc), and are prohibited, by George Washington University policy, from receiving any payment, royalties, or other fees from AMS Inc. Ms Draper is an employee and shareholder of AMS Inc.
Reprint requests to ICU Research Unit, George Washington University Medical Center, 2300 K St NW, Washington, DC 20037 (Dr Knaus).
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