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John E. Heffner, MD; Celia Barbieri, MS; Phil Fracica, MD; Lee K. Brown, MD

Arch Intern Med. 1998;158:1090-1095.

Background  Do-not-resuscitate (DNR) orders for critically ill patients are frequently miscommunicated between attending physicians, house staff, and nurses. A computer-based system was developed to improve the communication of a procedure-specific DNR order form.

Methods  Concordance of understanding of patients' DNR status was measured with the use of unstructured DNR orders (period 1), procedure-specific DNR order forms (period 2), and procedure-specific DNR order forms administered with a computer-based communication system (period 3). The 3 components of the DNR order assessed were (1) the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld.

Results  For the 147 patients, the computer-based system in period 3 (n=71) improved concordance for attending physicians and nurses or residents for all 3 of the DNR components compared with period 1 (n=40) and some of the DNR components compared with period 2 (n=36). Concordance was "substantial" or "almost perfect" as measured by the statistic during period 3. The proportion of agreement for the composite of all 3 components of the DNR order increased during each period (P<.001, period 3 vs period 1). Overall agreement between all caregivers for the composite DNR order also improved from period 1 (22.2%) to period 2 (47.8%) and period 3 (61.9%; P<.001 vs period 1). Errors in order entry were detected by physicians because of the computer system and corrected in 9.9% of DNR orders in period 3. Progress note documentation of DNR status did not improve during period 3. The procedures of period 3 were considered acceptable by the physician and nursing staff.

Conclusion  A computer-based system combined with a procedure-specific DNR order form improves communication of patients' DNR status in a critical care setting.

From the Department of Medicine, St Joseph's Hospital and Medical Center, Phoenix, Ariz (Drs Heffner, Fracica, and Brown and Ms Barbieri), and University of Arizona Health Sciences Center, Tucson (Drs Heffner, Fracica, and Brown).

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