Out-of-hospital do-not-resuscitate orders by primary care physicians

The objective of this study was to determine the knowledge, utilization, and experience of primary care physicians (PCPs) with nonhospital do-not-resuscitate (NH-DNR) orders. An anonymous survey was sent to all PCPs in a single northeastern county. Up to two surveys were mailed to each PCP. Descriptive statistics were used to report provider responses. The main variable of interest was issuance of NH-DNR orders. Surveys were mailed to 820 PCPs; 348 (42%) were returned. Respondents had practiced an average 17 +/- 11 years, and cared for an average of 720 patients per month, 7 of whom were terminally ill. Seventy percent issued NH-DNR orders. Twenty-five percent reported resuscitation had been attempted for at least one patient with a NH-DNR order; 64% reported this had happened more than once. Of respondents who had a NH-DNR order ignored, 14% had instructed family members to call police, fire, or EMS following death of the patient. Of the PCPs who did not issue NH-DNR orders, 71% reported not caring for any appropriate patients, yet 41% reported caring for at least 1 terminally ill patient per month. Seventy-nine percent disagreed that intubation and mechanical ventilation were appropriate treatment for DNR patients in severe respiratory distress, and 71% disagreed that cardioversion was appropriate treatment for an unconscious DNR patient with unstable ventricular tachycardia. In conclusion, a majority of respondents issued NH-DNR orders and one quarter reported these orders had not been followed. A majority felt intubation, mechanical ventilation, and cardioversion should not be performed for noncardiac arrest DNR patients with an indication, but not in cardiac arrest.