DNR orders at a tertiary care hospital--are they appropriate?

There are no established recommendations in Switzerland on when, how and for what patients DNR orders should be written. Moreover, little is known about current attitudes, patients' preferences, patients' involvement in decision-making and the adequacy of such decisions. The study was conducted in a Swiss tertiary care hospital to investigate the epidemiology, manner of application and appropriateness of DNR orders.

We performed retrospective chart review of all patients admitted to the department of general internal medicine of a Swiss tertiary care university hospital during four randomly selected months of the year 1998 (group 1) as well as of all patients who died in the department during 1998 (group 2). We assessed the frequency of DNR orders on admission and before death, their association with age, sex, diagnostic category, comorbidity and physical/social dependence, and the frequency of patient and/or family involvement in decision-making.

On admission, a DNR order was written for 15% of all hospitalised patients and 54% of the patients dying during the observation period; 93% of patients ultimately dying were the subject of DNR orders before death. There was a significant association between DNR orders and patients' age (p <0.001), physical and/or social dependence (p <0.001) and the admission diagnoses malignancy (p <0.001) or acute stroke (p <0.005). Cardiovascular disease was in inverse ratio to DNR orders (p <0.001). Only 6% of either patients or families were reportedly involved in decisions in the overall group, whereas this was the case in 58% of patients who died in hospital.

The frequency of DNR orders on admission was rather high. Referring to pre-arrest morbidity, DNR orders were often inappropriate on hospital admission but usually became so during hospital stay. After exclusion of confounding factors, age was the main independent factor for DNR orders. Patient and/or surrogate involvement in decision-making for DNR orders was low, thereby raising important ethical issues such as patient autonomy. An urgent national discussion on the topic is needed.