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  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Social Bookmarking   What's this?

Elizabeth E. O'Toole, MD; Stuart J. Youngner, MD; Barbara W. Juknialis, MA; Barbara Daly, RN, MSN; Edward T. Bartlett, PhD; C. Seth Landefeld, MD

Arch Intern Med. 1994;154(4):425-432.

Abstract
Background
Concerns about misinterpretation, misunderstanding, poor communication, and lack of documentation prompted a revision of our hospital's treatment limitation policy. The revised policy was designed to explicate do-not-resuscitate (DNR) orders, structure the use of DNR and other treatment-limiting orders in a logical and standard way, and improve communication. Use of a Specific Treatment-Limiting Order Page (STOP) was required.

Methods
To evaluate the policy's effects, we conducted (1) a prospective cohort study (involving 2733 patients) of treatment limitation practices before and after the new policy and (2) cross-sectional surveys of 58 nurses and 62 physicians. Outcome measures included documented treatment-limiting orders, documented discussions of these decisions, and deaths. Staff opinions about effects on communication and patient care were elicited.

Results
Rates of death (5.4% before and 5.6% after the policy; P=.80) and rates of DNR orders (9.3% vs 9.2%, P=.9) did not change. The use of the STOP enhanced the clarity of DNR orders and, among DNR patients, greatly increased the frequency of orders limiting 12 other specific treatments for conditions short of arrest. For example, before the policy, orders prohibited mechanical ventilation in 2% of DNR patients, compared with 66% after the policy (P<.001). Staff reported that the policy improved communication among health professionals, patients, and families.

Conclusions
The treatment limitation policy with the STOP improved documentation and communication of treatment-limiting decisions. On the basis of our results, we offer a STOP for use and evaluation by others.

(Arch Intern Med. 1994;154:425-432)

Author Affiliations
From the Division of General Internal Medicine, Department of Medicine (Drs O'Toole, Youngner, and Landefeld and Ms Juknialis), and Department of Medical and Surgical Nursing (Ms Daly), University Hospitals of Cleveland (Ohio); Case Western Reserve University School of Medicine, Cleveland (Drs O'Toole, Youngner, and Landefeld); and Cleveland State University (Dr Bartlett).

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

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

The Quality of Care Plans for Patients With Do-Not-Resuscitate Orders
Sulmasy et al.
Arch Intern Med 2004;164:1573-1578.
ABSTRACT | FULL TEXT  

Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders: Placing DNR Orders in the Context of a Life-Threatening Conditions Care Plan
Berger
Arch Intern Med 2003;163:2270-2275.
ABSTRACT | FULL TEXT  

Determining resuscitation preferences of elderly inpatients: a review of the literature
Frank et al.
CMAJ 2003;169:795-799.
ABSTRACT | FULL TEXT  

CPR for Patients Labeled DNR: The Role of the Limited Aggressive Therapy Order
Choudhry et al.
ANN INTERN MED 2003;138:65-68.
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  

Communicating Do-Not-Resuscitate Orders With a Computer-Based System
Heffner et al.
Arch Intern Med 1998;158:1090-1095.
ABSTRACT | FULL TEXT  

Procedure-Specific Do-Not-Resuscitate Orders: Effect on Communication of Treatment Limitations
Heffner et al.
Arch Intern Med 1996;156:793-797.
ABSTRACT  

Cardiopulmonary Resuscitation in Intensive Care Unit and Non--Intensive Care Unit Patients: Immediate and Long-term Survival
Karetzky et al.
Arch Intern Med 1995;155:1277-1280.
ABSTRACT