Code Status Blues: Do Legal Nudges Discourage Doctors From Ordering Do-Not-Resuscitate?

Area of Science:

• Medical Law and Ethics
• Health Policy Research
• Clinical Practice Guidelines

Background:

• Laws significantly influence healthcare practitioner behavior and patient care.
• Do-not-resuscitate (DNR) orders are critical for end-of-life care, ensuring patient autonomy.
• Texas Senate Bill 11 (SB 11), effective April 1, 2018, complicated DNR order issuance.

Purpose of the Study:

• To evaluate the impact of Texas SB 11 on the utilization of DNR orders.
• To determine if DNR order implementation decreased after the law's enactment.

Main Methods:

• Retrospective cohort chart review of adult patients at a Texas academic urban tertiary care hospital.
• Analysis of code status orders for 5426 critically ill patients before and after SB 11 implementation.
• Primary outcome: proportion of patients with DNR orders at hospitalization end.

Main Results:

• Implementation of SB 11's documentation and witnessing requirements correlated with a substantial decline in DNR orders.
• The decline was particularly notable among patients at the highest risk of mortality.

Conclusions:

• This study is the first to examine DNR usage decline post-legislation.
• The Texas law may have a chilling effect on physicians' ability to issue appropriate DNR orders.
• Patient rights to forgo resuscitation may be threatened by the law's complexity.