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Do-not-resuscitate orders in intensive care units. Current practices and recent changes
R L Jayes1, J E Zimmerman, D P Wagner
1Department of Medicine, George Washington University Medical Center, Washington, DC 20037.
JAMA
|November 10, 1993
Summary
Physicians are writing do-not-resuscitate (DNR) orders more frequently and earlier in intensive care units (ICUs). This shift reflects improved communication and understanding of outcomes, leading to better patient care and reduced mortality rates.
Area of Science:
- Critical Care Medicine
- Medical Ethics
- Health Services Research
Background:
- Do-not-resuscitate (DNR) orders are crucial for end-of-life care decisions in intensive care units (ICUs).
- Understanding trends in DNR order frequency and timing is essential for evaluating critical care practices.
Purpose of the Study:
- To characterize patients with DNR orders in ICUs.
- To determine the frequency and timing of DNR orders in a national ICU sample.
- To compare DNR practices between 1980-1990 and earlier periods (1979-1982).
Main Methods:
- Prospective inception cohort study.
- Data collected from 42 ICUs across 40 US hospitals (1988-1990).
- Analysis of 17,440 consecutive ICU admissions, including patient demographics, comorbidities, and illness severity.
Main Results:
- DNR orders were present in 9% of ICU admissions, with significant variation across hospitals.
- Patients with DNR orders were older, had more comorbidities, and higher illness severity.
- ICU DNR orders increased from 5.4% (1979-1982) to 9% (1988-1990), with orders placed earlier and preceding more deaths.
Conclusions:
- Physicians and families are setting limits on care earlier and more frequently for patients with poor prognoses.
- Increased dialogue and knowledge of treatment outcomes likely drive these practice changes.
- These trends preceded the Patient Self-determination Act, highlighting evolving end-of-life care discussions.