Roadblocks to do-not-resuscitate orders. A study in policy implementation

Cardiopulmonary resuscitation, a potentially lifesaving procedure, is initiated on hospitalized patients who have an arrest in the absence of a written do-not-resuscitate (DNR) order. New York State Law specifies that attending physicians may write a DNR order on an adult patient either with his/her consent or that of a surrogate. Under specified circumstances, concurring physician and witness signatures are also required. This study examines potential obstacles physicians may encounter when implementing a DNR order for a hospitalized patient.

Sixty house staff officers and 45 attending physicians at two New York City medical centers responded to a questionnaire listing 18 potential problems in obtaining a DNR order. Using a Likert scale, respondents rated the prevalence of each problem.

Analysis of the data indicates that attending physician's failure to discuss DNR issues with patients and situations involving surrogate decision making are considered major obstacles to obtaining a DNR order. Procedural regulations, including abundant paperwork and witnessed signatures, are not identified as major obstacles.

This study suggests a need for improved communication among physicians, patients, and surrogates about advance directives, when feasible, either prior to hospitalization or early in its course, in an effort to comply with DNR legislation in a manner that reflects the patient's wishes and best interests.