Factors Associated With Do-Not-Resuscitate Orders: Patients' Preferences, Prognoses, and Physicians' Judgments
Hakim, Rosemarie B.
Teno, Joan M.
Harrell, Frank E.
Knaus, William A.
Phillips, Russell S.
Connors, Alfred F.
Annals of Internal Medicine. 1996 Aug 15; 125(4): 284-293.
BACKGROUND: Medical treatment decisions should be based on the preferences of informed patients or their proxies and on the expected outcomes of treatment. Because seriously ill patients are at risk for cardiac arrest, examination of do-not-resuscitate (DNR) practices affecting them provides useful insights into the associations between various factors and medical decision making. OBJECTIVE: To examine the association between patients' preferences for resuscitation (along with other patient and physician characteristics) and the frequency and timing of DNR orders. DESIGN: Prospective cohort study. SETTING: 5 teaching hospitals. PATIENTS: 6802 seriously ill hospitalized patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) between 1989 and 1994. MEASUREMENTS: Patients and their surrogates were interviewed about patients' cardiopulmonary resuscitation preferences, medical records were reviewed to determine disease severity, and a multivariable regression model was constructed to predict the time to the first DNR order. RESULTS: The patients' preference for cardiopulmonary resuscitation was the most important predictor of the timing of DNR orders, but only 52% of patients who preferred not to be resuscitated actually had DNR orders written. The probability of surviving for 2 months was the next most important predictor of the timing of DNR orders. Although DNR orders were not linearly related to the probability of surviving for 2 months, they were written earlier and more frequently for patients with a 50% or lower probability of surviving for 2 months. Orders were written more quickly for patients older than 75 years of age, regardless of prognosis. After adjustment for these and other influential patient characteristics, the use and timing of DNR orders varied significantly among physician specialties and among hospitals. CONCLUSIONS: Patients' preferences and short-term prognoses are associated with the timing of DNR orders. However, the substantial variation seen among hospital sites and among physician specialties suggests that there is room for improvement. In this study, DNR orders were written earlier for patients older than 75 years of age, regardless of prognosis. This finding suggests that physicians may be using age in a way that is inconsistent with the reported association between age and survival. The process for making decisions about DNR orders needs to be improved if such orders are to routinely and accurately reflect patients' preferences and probable outcomes.
Age Factors; Aged; Attitudes; Cancer; Communication; Coma; Decision Making; Diagnosis; Disease; DNR Orders; Evaluation; Evaluation Studies; Family Members; Heart Diseases; Hospitals; Institutional Policies; Internal Medicine; Life; Medical Records; Medical Specialties; Medicine; Mortality; Patient Participation; Patients; Physicians; Probability; Prognosis; Quality of Life; Records; Resuscitation; Resuscitation Orders; Risk; Selection for Treatment; Statistics; Surgery; Survey; Terminally Ill; Time Factors; Treatment Refusal; Ventilators;
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Factors Associated With Do-Not-Resuscitate Orders: Patients' Preferences, Prognoses, and Physicians' Judgments Hakim, Rosemarie B.; Teno, Joan M.; Harrell, Frank E.; Knaus, William A.; Wenger, Neil; Phillips, Russell S.; Layde, Peter; Califf, Robert; Connors, Alfred F.; Lynn, Joanne (1996-08-15)
A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) Connors, Alfred F.; Dawson, Neal V.; Desbiens, Norman A.; Fulkerson, William J.; Goldman, Lee; Knaus, William A.; Lynn, Joanne; Oye, Robert K.; Harrell, Frank E.; Phillips, Russell S.; Teno, Joan; Wenger, Neil S. [Writing Group for the SUPPORT Investigators] (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT] Investigators, 1995-11-22)
The SUPPORT Prognostic Model: Objective Estimates of Survival for Seriously Ill Hospitalized Adults Knaus, William A.; Harrell, Frank E.; Lynn, Joanne; Goldman, Lee; Phillips, Russell S.; Connors, Alfred F.; Dawson, Neal V.; Fulkerson, William J.; Califf, Robert M.; Desbiens, Norman; Layde, Peter; Oye, Robert K.; Bellamy, Paul E.; Hakim, Rosemarie B.; Wagner, Douglas P. (1995-02-01)