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Toward an Understanding of What Do-Not-Resuscitate Orders Mean and How They Affect Patients

Neil S. Wenger, MD, MPH; Marjorie L. Pearson, PhD, MSHS; Katherine A. Desmond, MS; Robert H. Brook, MD, ScD; Katherine L. Kahn, MD

Arch Intern Med. 1995;155(19):2063-2068.

Abstract
Objectives
To evaluate the outcomes of hospitalized patients with do-not-resuscitate (DNR) orders and to identify variables that may elucidate the high mortality of patients with DNR orders.

Methods
Among a nationally representative sample of Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture, we retrospectively studied in-hospital and 180-day mortality and hospital lengths of stay for patients without DNR orders, with early (day 1 or 2) DNR orders, and with late (day 3 or later) DNR orders, before and after adjustment for sickness at hospital admission and patient and hospital characteristics.

Results
In-hospital mortality for patients with DNR orders exceeded that for patients without DNR orders before adjustment (59% vs 8%, P<.001), and after accounting for differences in sickness at admission and patient and hospital characteristics (40% vs 9%, P<.001). Sicker patients were assigned earlier DNR orders. Yet, patients with early DNR orders had a lower adjusted in-hospital mortality (31% vs 49%, P<.001) and shorter hospital stay (10 vs 18 days, P<.001) than did patients with late DNR orders.

Conclusions
Hospitalized older patients with DNR orders have a much higher mortality than predicted by admission demographic and clinical characteristics. The differential association of early and late DNR orders with mortality indicates that DNR orders represent a heterogeneous group of interventions that may be a marker of unmeasured sickness and a determinant of quality of care. A better understanding of what the DNR order represents and its effect on patient care is needed to ensure optimal use.

(Arch Intern Med. 1995;155:2063-2068)

Author Affiliations
From the Division of General Internal Medicine and Health Services Research, Department of Medicine (Drs Wenger, Brook, and Kahn), and Department of Health Services (Dr Brook), UCLA, Los Angeles, Calif; and Health Program of RAND, Santa Monica, Calif (Drs Pearson, Brook, and Kahn and Ms Desmond).

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