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Impediments to Writing Do-Not-Resuscitate Orders
COL Arn H. Eliasson, MD;
LTC Joseph M. Parker, MD;
CPT Andrew F. Shorr, MD;
LTC Katherine A. Babb, RN;
LTC Roy Harris, RN;
MAJ Barry A. Aaronson, MD;
COL Margretta Diemer, MD
Arch Intern Med. 1999;159:2213-2218.
Background Physicians are frequently unaware of their patients' desires regarding end-of-life care. Consequently, opportunities to implement do-not-resuscitate (DNR) orders are often missed.
Objective To determine the reasons attending physicians do not write DNR orders when patients face increased mortality.
Methods Over 4 months, the medical records of all inpatients on the General Medicine Service were reviewed at the time of discharge to identify patients with conditions predicting increased mortality. These cases were presented to a 5-member panel who decided if a DNR order was indicated. Reasons for missing DNR orders were discussed with the attending physicians.
Results Of 613 consecutive admissions, the panel identified 149 patients (24%) for whom DNR orders were indicated. In 88 (59%) of these, DNR orders were absent. The lack of a DNR order did not correlate with age (P=.95), sex (P=.61), or race (P=.80). The attending physicians' explanations for not writing DNR orders in these 88 cases included the belief that the patient was not in imminent danger of death (n=49 [56%]), the belief that the primary physician should discuss DNR issues (n=43 [49%]), and the lack of an appropriate opportunity to discuss end-of-life issues (n=38 [43%]). In 11 (12%) of the 88 cases, patients or their families did not accept the recommendation for a DNR order. No physicians expressed concerns regarding the morality of DNR orders, discomfort discussing end-of-life issues, or the threat of litigation as reasons for not writing a DNR order.
Conclusions Limitations in the extent and depth of the physician-patient relationship appear to be the most frequent impediments to writing DNR orders in our institution.
From the Departments of Medicine (Drs Eliasson, Parker, Shorr, Aaronson, and Diemer), Nursing (Ms Babb and Mr Harris), and Clinical Investigation (Dr Eliasson), Walter Reed Army Medical Center, Washington, DC; and the Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (Drs Eliasson, Parker, Shorr, Aaronson, and Diemer).
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