Do-not-resuscitate orders, unintended consequences, and the ripple effect

Area of Science:

• Critical Care Medicine
• Medical Ethics
• Health Services Research

Background:

• Do-not-resuscitate (DNR) orders are standard in critical care, influencing end-of-life care decisions.
• Decisions are often based on prognosis, patient/family wishes, and physician judgment.
• The hospital environment may affect care aggressiveness beyond individual DNR status.

Purpose of the Study:

• To explore how hospital culture around DNR orders influences care aggressiveness.
• To examine the potential impact on patient outcomes, even for those without DNR orders.
• To understand the broader implications of DNR implementation in critical care settings.

Main Methods:

• Qualitative analysis of hospital culture and DNR order implementation.
• Case study approach, using intracerebral hemorrhage as an example.
• Review of care aggressiveness metrics and patient outcomes.

Main Results:

• Hospital culture significantly influences the interpretation and implementation of DNR orders.
• Aggressiveness of care can be indirectly affected by the prevailing milieu surrounding DNR decisions.
• Outcomes for patients without DNR orders can be unexpectedly influenced by this broader culture.

Conclusions:

• The hospital environment and culture surrounding DNR orders have a pervasive effect on patient care.
• This cultural influence can impact outcomes even for patients not directly involved in DNR discussions.
• Further research is needed to quantify and mitigate unintended consequences of DNR policies on care aggressiveness.