Do-not-resuscitate orders in the last days of life

The purpose of this analysis was to describe the presence and timing of do-not-resuscitate (DNR) orders for imminently dying patients in VA Medical Centers, and to examine factors associated with these processes.

Data on DNR orders in the last 7 days of life were abstracted from the medical records of 1,069 veterans who had died in one of six VA hospitals in 2005.

Of the 1069 records, 681 (63.7%) had an active DNR order at time of death. Among these, records indicated that the order was written within the last 24 hours for 219 (32.2%), 1-2 days prior to death for 54 (7.9%), 3-7 days prior to death for 256 (37.6%), and > 7 days prior to death for 152 (22.3%). Veterans with a family member present at time of death and those who received pastoral care visits were more likely to have DNR orders. African American veterans and veterans who died unexpectedly were less likely to have DNR orders. Compared with those dying on a general medicine unit, veterans dying in the emergency department or an intensive care unit (ICU) and veterans dying during a procedure or in transit were less likely to have DNR orders. Mental health diagnoses were not associated with presence of a DNR order.

Results suggest that the DNR process might be improved by interventions that target ICU settings, facilitate transitions to less intensive locations of care, ensure the involvement and availability of pastoral care staff, and create environments that support the presence of family members.