Improving Awareness and Communication of Do Not Resuscitate Orders During Transitions of Care

Do not resuscitate (DNR) orders are not always documented at transitions of care, which may lead to inappropriate resuscitation attempts. The objectives of this study were (1) to investigate the challenges in ensuring that all staff are aware of patients' DNR orders, (2) to examine documentation of DNR orders at transitions of care, and (3) to improve knowledge about DNR orders in institutions and at transitions of care.

This intervention initiative with pre- and post-measurements (2020 and 2023) involved hospital departments and nursing homes in Denmark. The intervention consisted of a practical instruction brochure and an end-of-life presentation. The measurements included audits of resuscitation attempts and of DNR order documentation at transitions of care. Furthermore, the participating institutions completed an electronic survey on perceived challenges.

Thirty nursing homes and eight hospital departments participated in pre-measurement, 20 nursing homes and seven hospital departments participated in post-measurement, and 17 to 20 sites were included in paired analyses. The number of inappropriate resuscitation attempts was identical at pre- and post-measurements (none in nursing homes and five at the hospital). Correct documentation in nursing reports at hospital discharge increased from 32% to 53% (p = 0.003). Participating units that did not perceive challenges in ensuring knowledge of DNR orders increased from 10% to 48% (p < 0.001). At post-measurement, more than 80% of participating units had worked with models to ensure awareness of DNR orders and inclusion of DNR orders at transitions of care.

Participants experienced a significant increased focus on DNR orders in their own departments. Likewise, a significant increase in communication of DNR orders at transitions of care was found.