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The Quality of Care Plans for Patients With Do-Not-Resuscitate Orders
Daniel P. Sulmasy, OFM, MD, PhD;
Johanna R. Sood, MA;
Wayne A. Ury, MD
Arch Intern Med. 2004;164:1573-1578.
Background Care plans for patients with do-not-resuscitate (DNR) orders often fail to define limits other than cardiopulmonary resuscitation and fail to address other patient care needs. We studied the explicitness and comprehensiveness of care plans for patients with DNR orders and what factors were associated with this aspect of the quality of their care.
Methods A cross-sectional study was conducted at Georgetown University Medical Center (GUMC), Washington, DC, and St Vincent Catholic Medical Centers (SVCMC), St Vincent's Hospital–Manhattan, New York, NY. Participants included 189 consecutive medical inpatients with DNR orders.
Results A previously validated medical chart review technique termed concurrent care concerns (CCCs) measured whether 11 possible patient care needs had been addressed within 2 days of the DNR order. Reasons for the DNR order were documented in only 55% of cases, and a consent conversation was documented in only 69%. The mean number of total CCCs per DNR order was 1.55 (1.84 at GUMC and 1.29 at SVCMC; (P = .007). In a multivariate logistic regression analysis of low ( 1) vs high ( 2) CCCs, patients with malignancy (P = .002), higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (P = .007), and a documented consent conversation (P = .009) and those at Georgetown (P = .005) were more likely to have high attention to CCCs. Patients with dementia were the least likely to have high attention to CCCs.
Conclusions Documented consent conversations and care plans for patients with DNR orders are less than ideal. Care plans differ in quality by diagnosis, institution, and whether or not a consent conversation is documented. These observations might help to guide interventions that aim to improve the care of patients with DNR orders.
From the John J. Conley Department of Ethics (Drs Sulmasy and Ury and Ms Sood), and the Section of Palliative Care, Department of Medicine (Dr Ury), St Vincent's Hospital–Manhattan, New York, NY; and the Bioethics Institute of New York Medical College, Valhalla, NY (Drs Sulmasy and Ury). The authors have no relevant financial interest in this article.
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