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?

Laura B. Shepardson, MS; Stuart J. Youngner, MD; Theodore Speroff, PhD; Ralph G. O'Brien, PhD; Kathleen A. Smyth, PhD; Gary E. Rosenthal, MD

Arch Intern Med. 1997;157(16):1841-1847.

Abstract
Objectives
To identify sociodemographic and clinical characteristics associated with the use of do-not-resuscitate (DNR) orders in hospitalized patients with stroke. To examine whether the use of DNR orders varies across hospitals.

Methods
This observational cohort study used data collected for 13 337 consecutive eligible patients with a primary diagnosis of stroke. These patients were discharged in 1991 through 1994 from 30 hospitals in a large metropolitan area. Study data were abstracted from patients' hospital records using standard forms. Admission severity of illness was measured using a validated multivariable model. Sociodemographic and clinical factors independently associated with the use of DNR orders were identified using stepwise logistic regression.

Results
Do-not-resuscitate orders were written for 2898 patients (22%). Patient characteristics independently (P<.01) associated with increased use of DNR orders included increasing age (odds ratio [OR], 1.06 per year); admission from a skilled nursing facility (OR, 2.44) or through the emergency department (OR, 1.49); cancer (OR, 2.73), intracerebral hemorrhage (OR, 2.12), coma (OR, 7.47), or lethargy or stupor on admission neurological assessment (OR, 3.38); and increasing admission severity (OR, 1.29 per decile). In contrast, African American race was associated with lower use of DNR orders (OR, 0.54). Although substantial variation in the use of DNR orders was observed across hospitals, with rates ranging from 12% to 32%, adjusting for the above patient characteristics eliminated much of this variation, including differences between major teaching and other hospitals and between hospitals with and without religious affiliations.

Conclusions
In our community-based analysis of patients with stroke, the use of DNR orders was common and was strongly related to several patient characteristics. These factors explained much of the variation across hospitals. While our analysis did not account for differences in patient preferences for treatment, the differences we observed in the use of DNR orders across sociodemographic groups are suggestive of variations in care and may have important implications for the cost and quality of hospital care.

Arch Intern Med. 1997;157:1841-1847

Author Affiliations
From the Department of Epidemiology and Biostatistics (Ms Shepardson and Drs Speroff, Smyth, and Rosenthal), Division of General Internal Medicine and Health Care Research (Drs Youngner and Rosenthal), Cleveland Veterans Affairs Medical Center and University Hospitals of Cleveland; Clinical Ethics Program, University Hospitals of Cleveland and Center for Biomedical Ethics (Dr Younger), Case Western Reserve University School of Medicine (Ms Shepardson and Drs Youngner, Speroff, and Smyth); and the Department of Biostatistics, Cleveland Clinic Foundation (Dr O'Brien), Cleveland, Ohio.

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

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Age, invasive ventilatory support and outcomes in elderly patients admitted to intensive care units
Farfel et al.
Age Ageing 2009;38:515-520.
ABSTRACT | FULL TEXT  

Lack of Ethnic Differences in End-of-Life Care in the Veterans Health Administration
Fischer et al.
AM J HOSP PALLIAT CARE 2007;24:277-283.
ABSTRACT  

Early care limitations independently predict mortality after intracerebral hemorrhage
Zahuranec et al.
Neurology 2007;68:1651-1657.
ABSTRACT | FULL TEXT  

Process of care and mortality of stroke patients with and without a do not resuscitate order in the West Midlands, UK
Mohammed et al.
Int J Qual Health Care 2006;18:102-106.
ABSTRACT | FULL TEXT  

Regional and Institutional Variation in the Initiation of Early Do-Not-Resuscitate Orders
Zingmond and Wenger
Arch Intern Med 2005;165:1705-1712.
ABSTRACT | FULL TEXT  

Cardiopulmonary resuscitation is not addressed in the admitting medical records for the majority of patients who undergo CPR in the hospital
Mirza et al.
AM J HOSP PALLIAT CARE 2005;22:20-25.
ABSTRACT  

Hospital Usage of Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage
Hemphill et al.
Stroke 2004;35:1130-1134.
ABSTRACT | FULL TEXT  

Do-Not-Resuscitate Orders in Patients Hospitalized With Acute Myocardial Infarction: The Worcester Heart Attack Study
Jackson et al.
Arch Intern Med 2004;164:776-783.
ABSTRACT | FULL TEXT  

Effects of Religiosity on Patients' Perceptions of Do-Not-Resuscitate Status
Sullivan et al.
Psychosomatics 2004;45:119-128.
ABSTRACT | FULL TEXT  

ICH Score in a Rural Village in the Republic of Argentina * Response * Response
Godoy et al.
Stroke 2003;34 :e150-e151.
FULL TEXT  

The effect of pneumonia on mortality among patients hospitalized for acute stroke
Katzan et al.
Neurology 2003;60:620-625.
ABSTRACT | FULL TEXT  

Increasing use of DNR orders in the elderly worldwide: whose choice is it?
Cherniack
J. Med. Ethics 2002;28:303-307.
ABSTRACT | FULL TEXT  

Lack of Relationship Between the Cleveland Health Quality Choice Project and Decreased Inpatient Mortality in Cleveland
Clough et al.
American Journal of Medical Quality 2002;17:47-55.
ABSTRACT  

Measuring patients' preferences for treatment and perceptions of risk
Bowling and Ebrahim
Qual Saf Health Care 2001;10:i2-8.
FULL TEXT  

Racial Differences in Mortality among Elderly Patients Admitted for Heart Failure
Ibrahim et al.
Research on Aging 2001;23:457-472.
ABSTRACT  

Do not resuscitate decisions: flogging dead horses or a dignified death?
Ebrahim
BMJ 2000;320:1155-1156.
FULL TEXT  

Community-Wide Assessment of Intensive Care Outcomes Using a Physiologically Based Prognostic Measure: Implications for Critical Care Delivery From Cleveland Health Quality Choice
Sirio et al.
Chest 1999;115:793-801.
ABSTRACT | FULL TEXT