Do-not-resuscitate orders for critically ill patients in the hospital. How are they used and what is their impact?

BACKGROUND: The meaning of do-not-resuscitate orders and their impact on nursing care have been a source of confusion, and the results of the few studies that have examined nursing care of ICU patients with these orders have been conflicting. OBJECTIVES: To assess nursing workload associated with caring for patients with do-not-resuscitate orders and to better understand the patients and selected events associated with these orders. METHOD: Sixty patients from medical, surgical, and neuroscience ICUs met the criteria for the study. The Medicus Systems Corporation InterAct 2000 Workload and Productivity System was used to classify patients by type; the results reflected the number of hours of nursing care required per 24 hours. Data on patient type for 1 day before and 1 day after do-not-resuscitate orders were written were available for 31 of the 60 patients. These data were analyzed. RESULTS: The number of hours of nursing care required 1 day before and 1 day after a do-not-resuscitate order did not change. The amount of nursing care remained the same or increased for 74% (23/31) of the patients after the order was written. Patients were classified as types IV (n = 8), V (n = 20), and VI (n = 3) after the order was written. CONCLUSIONS: A high level of nursing care was required for this group of critically ill patients, and the do-not-resuscitate order did not alter the number of hours of nursing care required after the order was written.

Download Full-text

Effect of do-not-resuscitate orders on the nursing care of critically ill patients

American Journal of Critical Care ◽

10.4037/ajcc1994.3.6.467 ◽

1994 ◽

Vol 3 (6) ◽

pp. 467-472 ◽

Cited By ~ 39

Author(s):

EA Henneman ◽

B Baird ◽

PE Bellamy ◽

LL Faber ◽

RK Oye

Keyword(s):

Cardiopulmonary Resuscitation ◽

Critically Ill ◽

Critically Ill Patients ◽

Standard Of Care ◽

Psychosocial Interventions ◽

Standards Of Care ◽

Spiritual Needs ◽

Do Not Resuscitate ◽

Hospital Policy ◽

Study Results

BACKGROUND. The effect of a do-not-resuscitate order on the standard of care of critically ill patients is of concern to practitioners, patients, and their families. Because "do not resuscitate" may be misconstrued to include more than "no cardiopulmonary resuscitation," it may influence the aggressiveness with which some patients are managed. Nurses play a central role in determining standards of care. Hence, confusion on their part as to the meaning of this term can have a significant impact on patient care. OBJECTIVES. To compare nurses' attitudes about standards of care for critically ill patients with and without a do-not-resuscitate order. METHOD. A quasi-experimental design using simulation measurement was used for this study. RESULTS. Nurses reported that they would be significantly less likely to perform a variety of physiologic monitoring modalities and interventions for patients with a do-not-resuscitate order than for patients without such an order. Patients with a do-not-resuscitate order were more likely to receive psychosocial interventions including assessment of their spiritual needs and more flexible visiting practices. CONCLUSIONS. Our findings suggest that "do-not-resuscitate" may be misinterpreted to include more than "no cardiopulmonary resuscitation" even if the patient is receiving aggressive medical management. Misinterpretation of orders not to resuscitate may be related to a variety of factors including lack of understanding about hospital policy and ethical and moral values of the staff. We suggest replacing orders such as "Do not resuscitate" with clearly defined resuscitation plans that are jointly determined by the multidisciplinary team, patient, and family.

Download Full-text

Do-not-resuscitate orders for critically ill patients in intensive care

Nursing Ethics ◽

10.1177/0969733010364893 ◽

2010 ◽

Vol 17 (4) ◽

pp. 445-455 ◽

Cited By ~ 23

Author(s):

Yuanmay Chang ◽

Chin-Feng Huang ◽

Chia-Chin Lin

Keyword(s):

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Life Support ◽

Adult Child ◽

Do Not Resuscitate ◽

Lack Of Information ◽

Surrogate Decision ◽

End Of Life Decision ◽

To Receive

End-of-life decision making frequently occurs in the intensive care unit (ICU). There is a lack of information on how a do-not-resuscitate (DNR) order affects treatments received by critically ill patients in ICUs. The objectives of this study were: (1) to compare the use of life support therapies between patients with a DNR order and those without; (2) to examine life support therapies prior to and after the issuance of a DNR order; and (3) to determine the clinical factors that influence the initiation of a DNR order in ICUs in Taiwan. A prospective, descriptive, and correlational study was conducted. A total of 202 patients comprising 133 (65.8%) who had a DNR order, and 69 (34.1%) who did not, participated in this study. In the last 48 hours of their lives, patients who had a DNR order were less likely to receive life support therapies than those who did not have a DNR order. Older age, being unmarried, the presence of an adult child as a surrogate decision maker, a perceived inability to survive ultimate discharge from the ICU, and longer hospitalization in the ICU were significant predictors of issuing a DNR order for critically ill patients. This study will draw attention to how, when, and by whom, critically ill patients’ preferences about DNR are elicited and honored.

Download Full-text

DO-NOT-RESUSCITATE ORDERS IN THE CRITICALLY ILL PATIENT – AN OBSERVATIONAL STUDY WITH SPECIAL EMPHASIS ON WITHHOLDING OF RENAL REPLACEMENT THERAPY

Acta Clinica Belgica ◽

10.1179/acb.2008.041 ◽

2008 ◽

Vol 63 (4) ◽

pp. 221-226 ◽

Cited By ~ 3

Author(s):

K. Janssen van Doorn ◽

M. Diltoer ◽

H. Spapen

Keyword(s):

Renal Replacement Therapy ◽

Observational Study ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patient ◽

Do Not Resuscitate ◽

Do Not Resuscitate Orders

Download Full-text

Survival After In-Hospital Cardiac Arrest In Critically Ill Patients Implications For The Covid-19 Pandemic?

10.1101/2020.04.11.20060749 ◽

2020 ◽

Author(s):

Saket Girotra ◽

Yuanyuan Tang ◽

Paul S. Chan ◽

Brahmajee K. Nallamothu

Keyword(s):

Mechanical Ventilation ◽

Cardiac Arrest ◽

Critically Ill ◽

Critically Ill Patients ◽

Survival Rates ◽

Ventilatory Support ◽

Survival Outcomes ◽

Do Not Resuscitate ◽

Neurological Disability ◽

Initial Rhythm

The coronavirus disease 2019 (COVID-19) outbreak is placing a considerable strain on U.S. healthcare systems. Due to presumptions of poor outcomes in such critically ill patients, many hospitals have started considering a universal do-not-resuscitate order in patients with confirmed Covid-19 given a limited supply of intensive care unit (ICU) beds and the potential risk of transmission of infection to healthcare workers during resuscitation. However, empirical data on survival of cardiac arrest in Covid-19 patients are unavailable at this time.To inform this debate, we report survival outcomes following cardiopulmonary resuscitation in a cohort of similar critically ill patients with pneumonia or sepsis who were receiving mechanical ventilation in an ICU at the time of arrest. The probability of survival without severe neurological disability (CPC of 1 or 2) ranged from less than 3% to over 22% across key patient subgroups, For patients with an initial rhythm of asystole or PEA, who were also receiving vasopressors at the time of arrest, fewer than 10% were discharged without severe neurological disability (CPC of 1 or 2), and this number dropped to less than 3% in patients over 80 years old. In contrast, survival rates were much higher in younger patients, patients with an initial rhythm of VF or pulseless VT, and in patients receiving ventilatory support without vasopressors.Our findings suggest caution in universal resuscitation policies. Even in a cohort of critically ill patients on mechanical ventilation, survival outcomes following in-hospital resuscitation were not uniformly poor and varied markedly depending on age, co-morbidities and illness severity. We believe that these data can help inform discussions among patients, providers and hospital leaders regarding resuscitation policies and goals of care in the context of the COVID-19 pandemic.

Download Full-text

Use of Do-Not-Resuscitate Orders for Critically Ill Patients with ESKD

Journal of the American Society of Nephrology ◽

10.1681/asn.2020010088 ◽

2020 ◽

Vol 31 (10) ◽

pp. 2393-2399 ◽

Cited By ~ 1

Author(s):

John Danziger ◽

Miguel Ángel Armengol de la Hoz ◽

Leo Anthony Celi ◽

Robert A. Cohen ◽

Kenneth J. Mukamal

Keyword(s):

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

The United States ◽

Chronic Obstructive ◽

Do Not Resuscitate ◽

Resuscitation Orders ◽

Increased Risk ◽

Major Organ ◽

Dnr Orders

BackgroundDespite having high comorbidity rates and shortened life expectancy, patients with ESKD may harbor unrealistically optimistic expectations about their prognoses. Whether this affects resuscitation orders is unknown.MethodsTo determine whether do-not-resuscitate (DNR) orders differ among patients with ESKD compared with other critically ill patients, including those with diseases of other major organs, we investigated DNR orders on admission to intensive care units (ICUs) among 106,873 patients in the United States.ResultsMajor organ disease uniformly associated with increased risk of hospital mortality, particularly for cirrhosis (adjusted odds ratio [aOR], 2.67; 95% confidence interval [95% CI], 2.30 to 3.08), and ESKD (aOR, 1.47; 95% CI, 1.31 to 1.65). Compared with critically ill patients without major organ disease, patients with stroke, cancer, heart failure, dementia, chronic obstructive pulmonary disease, and cirrhosis were statistically more likely to have a DNR order on ICU admission; those with ESKD were not. Findings were similar when comparing patients with a single organ disease with those without organ disease. The disconnect between prognosis and DNR use was most notable among Black patients, for whom ESKD (compared with no major organ disease) was associated with a 62% (aOR, 1.62; 95% CI, 1.27 to 2.04) higher odds of hospital mortality, but no appreciable difference in DNR utilization (aOR, 1.06; 95% CI, 0.66 to 1.62).ConclusionsUnlike patients with diseases of other major organs, critically ill patients with ESKD were not more likely to have a DNR order than patients without ESKD. Whether this reflects a greater lack of advance care planning in the nephrology community, as well as a missed opportunity to minimize potentially needless patient suffering, requires further study.

Download Full-text

Acquisition of Multidrug-Resistant Organisms Among Hospital Patients Hospitalized in Beds Adjacent to Critically Ill Patients

Infection Control and Hospital Epidemiology ◽

10.1086/505919 ◽

2006 ◽

Vol 27 (7) ◽

pp. 675-681 ◽

Cited By ~ 7

Author(s):

Matan J. Cohen ◽

Olga Anshelevich ◽

David Raveh ◽

Ellen Broide ◽

Bernard Rudensky ◽

...

Keyword(s):

Incidence Rate ◽

Critically Ill ◽

Critically Ill Patients ◽

Medical Center ◽

Multidrug Resistant ◽

Incidence Rates ◽

Critically Ill Patient ◽

Do Not Resuscitate ◽

Increased Risk ◽

Multidrug Resistant Pathogens

Objective.To assess whether patients hospitalized in beds physically adjacent to critically ill patients are at increased risk to acquire multidrug-resistant pathogens.Design.Cohort study.Setting.Shaare Zedek Medical Center, a 550-bed medical referral center.Patients.From April to September 2004, we enrolled consecutive newly admitted patients who were hospitalized in beds adjacent to either mechanically ventilated patients or patients designated as “do not resuscitate” (DNR). For each of these patients, we also enrolled a control patient who was not hospitalized in a bed adjacent to a critically ill patient. We collected specimens from the anterior nares, the oral cavity, and the perianal zone at the time of admission and subsequently at 3-day intervals until discharge or death. Specimens were cultured on selective media to detect growth of antibiotic-resistant pathogens, includingAcinetobacter baumannii, methicillin-resistantStaphylococcus aureus(MRSA), extended-spectrum β lactamase (ESBL)–producing Enterobacteriaceae, and vancomycin-resistant enterococci (VRE).Results.We enrolled 46 neighbor-control pairs. Among neighbors and controls, respectively, the incidence rates for isolation ofA. baumanniiwas 8.3 and 4 isolations per 100 patient-days (relative risk [RR], 2.1 [95% confidence interval {CI}, 0.8-5.2];P= .12), the incidence rates for MRSA were 1.4 and 2.6 isolations per 100 patient-days (RR, 0.6 [95% CI, 0.1-2.3];P= .45), the incidence rates for ESBL-producing Enterobacteriaceae were 10.5 and 9 isolations per 100 patient-days (RR, 1.2 [95% CI, 0.6-2.4];P= .84), the incidence rates for VRE were 4.3 and 4.8 isolations per 100 patient-days (RR, 0.9 [95% CI, 0.3-2.4];P= 1), and the composite incidence rate was 21.7 and 16.2 isolations per 100 patient-days (RR, 1.3 [95% CI, 0.8-2.3];P= 0.3).Conclusions.In this pilot study, we did not detect an increased incidence rate of isolation of multidrug-resistant pathogens among patients hospitalized in beds adjacent to critically ill patients. Further studies with larger samples should be conducted in order to generate valid data and provide patients, physicians, and policy makers with a sufficient knowledge base from which decisions can be made.

Download Full-text