We studied compliance with do-not-resuscitate (DNR) orders at a university hospital where a DNR protocol has existed since 1979. Documentation of DNR status in patient progress notes and chart orders increased through 1983. During a 12-month period (March 1983 through April 1984), we studied in detail the medical records of 521 patients who had a cardiopulmonary arrest in the hospital. Seventy-five percent (389 of 521) of these patients were designated DNR. Patients who were designated DNR were significantly more likely to be older, to have malignancy or an abnormal mental status, and to be less likely to have acute myocardial infarction, stroke, or chronic obstructive pulmonary disease than patients in whom resuscitation was attempted. Eighty-six percent of families, but only 22% of patients, were involved in the decision to designate a patient DNR. The decision to designate a patient DNR occurred late in the course of a patient's illness, often when the patient was in coma. For 28% of patients, some form of medical care was withdrawn or withheld after they were designated DNR. These data suggest that use of the DNR protocol requires changes if patients are to participate in the decision not to undergo cardiopulmonary resuscitation.
KIE: Records of 521 patients who suffered cardiopulmonary arrest during a 12-month period at the Harvard-affiliated Beth Israel Hospital were examined to determine compliance with the hospital's policy on do-not-resuscitate (DNR) orders. Seventy-five percent of the DNR patients were older and more likely to have a malignancy or an abnormal mental status than those on whom resuscitation was attempted. Families of 86% of the patients, but only 22% of the patients themselves, participated in the DNR decisions, which often were made after the patient was comatose. Some form of medical care was withdrawn or withheld from 28% of the patients after they had been designated DNR. The authors evaluated their data according to the four elements of the hospital's DNR policy--physician record keeping; involvement of patients, health personnel, and families in decision making; selection of patients designated DNR; and effect of a DNR order on subsequent medical care.