This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (44)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Social Bookmarking   What's this?

Alfred Maksoud, MD; Dennis W. Jahnigen, MD; Christine I. Skibinski, MS

Arch Intern Med. 1993;153(10):1249-1253.

Abstract
Background
The appropriate role of cardiopulmonary resuscitation in the hospital continues to be a topic of interest to physicians and patients alike. The use of do not resuscitate (DNR) orders reflects a growing expression of autonomy by patients to refuse medical treatment, and also a growing recognition of its futility in many circumstances by physicians. Although it has been suggested that wider use of advance directives will lead to a reduction in health care costs near the end of life, little empiric data exist to support this prediction. This study was designed to ascertain the rates of DNR orders and their associated costs.

Methods
A retrospective chart review was conducted on the hospital records of 852 of 953 hospital deaths that occurred in a referral hospital. Data were collected on resuscitation status, timing of DNR orders, participants in decision making, and physician and hospital charges.

Results
Of the 852 records reviewed, 625 (73%) had a DNR order at the time of death. The use of DNR orders for patients who died ranged from 97% of those on an oncology service to 43% of deaths on cardiology services. One hundred seven patients (17%) had the DNR order before admission. Of 512 patients who had a new DNR order in the hospital, approval was obtained from the patient in only 19%. Patients who died with a DNR order had longer hospital stays (median, 11.0 days) compared with those who died without a DNR order (6.0 days). The time from DNR order to death was 2 days overall with 2.0 days for medical patients and 1.0 day for surgical patients. Average charges for each patient who died were $61 215 with $10 631 for those admitted with a DNR order, and $73 055 for those who had a DNR order made in hospital.

Conclusion
This study demonstrates high variability in the use of DNR orders between various medical and surgical services. These range from a high of 98% on an oncology service to a low of 43% on cardiology. Most patients have a DNR order at the time of death, but these typically occur late in the course of the hospital stay. Death in the hospital is costly and total hospital and professional charges are significantly lower when a patient is admitted with an established nonresuscitation order compared with those for whom a DNR is established while in the hospital. This study provides a basis against which to measure the impact of efforts such as the Patient SelfDetermination Act of 1990 to increase the use of advance directives, as well as monitor their effect on health care expenditures.

(Arch Intern Med. 1993;153:1249-1253)

Author Affiliations
From the Cleveland (Ohio) Clinic Foundation.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act
Morrell et al.
J. Med. Ethics 2008;34:642-647.
ABSTRACT | FULL TEXT  

Cardiovascular Risk Profile Earlier in Life and Medicare Costs in the Last Year of Life
Daviglus et al.
Arch Intern Med 2005;165:1028-1034.
ABSTRACT | FULL TEXT  

Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital
Junod Perron et al.
J. Med. Ethics 2002;28:364-367.
ABSTRACT | FULL TEXT  

You need not make the journey alone: Overcoming impediments to providing palliative care in a public urban teaching hospital
Ryan et al.
AM J HOSP PALLIAT CARE 2002;19:171-180.
ABSTRACT  

The Attitudes of Black Americans Toward Advance Directives
Dupree
J Transcult Nurs 2000;11:12-18.
ABSTRACT  

Managed Care and Managed Death: Peas From the Same Pod?
McQuillen
Arch Neurol 1997;54:326-328.
ABSTRACT  

Cost Savings at the End of Life: What Do the Data Show?
Emanuel
JAMA 1996;275:1907-1914.
ABSTRACT  

Advance End-of-Life Treatment Planning
Miles et al.
Arch Intern Med 1996;156:1062-1068.
ABSTRACT  

Acute Care Costs of the Oldest Old: They Cost Less, Their Care Intensity Is Less, and They Go to Nonteaching Hospitals
Perls and Wood
Arch Intern Med 1996;156:754-760.
ABSTRACT  

Promoting Inpatient Directives About Life-Sustaining Treatments in a Community Hospital: Results of a 3-Year Time-Series Intervention Trial
Reilly et al.
Arch Intern Med 1995;155:2317-2323.
ABSTRACT  

Outcomes of Patients With Do-Not-Resuscitate Orders: Toward an Understanding of What Do-Not-Resuscitate Orders Mean and How They Affect Patients
Wenger et al.
Arch Intern Med 1995;155:2063-2068.
ABSTRACT  

Terminal Care of the Very Old: Changes in the Way We Die
Hesse
Arch Intern Med 1995;155:1513-1518.
ABSTRACT  

Health Care for Elderly Persons -- Myths and Realities
Kramer
NEJM 1995;332:1027-1029.
FULL TEXT  

The Naturalness of Dying
McCue
JAMA 1995;273:1039-1043.
ABSTRACT  

Advance Directives and the Cost of Terminal Hospitalization
Weeks et al.
Arch Intern Med 1994;154:2077-2083.
ABSTRACT  

The Economics of Dying -- The Illusion of Cost Savings at the End of Life
Emanuel and Emanuel
NEJM 1994;330:540-544.
FULL TEXT  

Do-Not-Resuscitate Orders and the Cost of Death
Rosner
Arch Intern Med 1994;154:348-348.
ABSTRACT