What, exactly, does a "do-not-resuscitate" (DNR) order mean? What about when it is applied to a child? A chilling article published as an original investigation in the August 26, 2013, issue of JAMA Pediatrics indicates that for many health care workers, a DNR is a signal not to deliver as much care, with as much diligence, as they otherwise would.
A team of researchers in Boston surveyed colleagues at Boston Children's Hospital and at Dana Farber Children's Hospital Cancer Center to determine their attitudes regarding DNR orders applied to children. Two hundred sixty-six individuals responded to the survey (107 doctors and 159 nurses). Although a DNR is a legal form filed with a hospital that specifically directs hospital personnel not to resuscitate the patient if his heart stops beating or he stops breathing, more than 85% of those surveyed believe that DNR orders are interpreted to mean general changes in care, including "less clinician attentiveness" and a shift toward comfort care. The authors of the article state, "Clinicians use the DNR order not only as a guide for therapeutic decisions during a cardiopulmonary arrest but also as a surrogate for broader treatment directives."
Although this data may be shocking, it is in keeping with earlier research, which has found that adult surgical patients with DNR orders on file have higher mortality rates than those who have not filed such orders. An original article in the August 2011 issue of JAMA Surgery states that in comparison with non-DNR patients, DNR patients experienced longer durations of hospital stay (36% increase), higher complication rates (31% for DNR vs. 26.4% for non-DNR), and -- perhaps most disturbing -- higher mortality rates (23.1% for DNR vs. 8.4% for non-DNR). The bulk of the DNR patients (63%) were in the hospital for non-emergency surgery, yet 16.6% of these individuals died. In short, DNR patients were more than twice as likely as non-DNR patients to die.
The JAMA Surgery article also found that DNR patients were more likely than non-DNR patients to have "contaminated or dirty operative wounds" and "surgery without assistance of a surgery resident." This finding is unsurprising, given previous findings of research into physicians' attitudes about patients with DNR orders on file. For example, a 2002 article in the Journal of the American Geriatrics Society states that "the presence of a DNR order may affect physicians' willingness to order a variety of treatments not related to CPR." Indeed, physicians in this 2002 study were significantly less likely to transfer a DNR patient to intensive care, and less likely to perform a blood test on a DNR patient.
One might expect physicians to react to such data with increased concern for the care of all patients, including those who would prefer not to be resuscitated in the case of cardiac arrest. However, this is not necessarily true. In an interview with Reuters Health, Dr. Saziana Roman, one of the authors of the 2011 study cited earlier, indicated that physicians should attempt to talk DNR patients out of surgery: "We can now say, 'Look, you have a really high chance of dying. Do you even want to go through this?'" Rather than recognizing that a lower level of physician care -- such as leaving operative wounds dirty or not asking a surgical resident for assistance -- may be responsible for the relatively greater mortality rate of DNR patients, Dr. Roman appears to believe that patients who would prefer not to be resuscitated in the event of cardiac arrest may not deserve treatment at all.
Given that the data suggest poorer care and physicians' propensity to prefer palliative care to therapeutic care for individuals who have a DNR on file, it may be wise for individuals to choose an option other than a DNR to ensure that physicians' judgment and / or prejudices not be substituted for the patients' own wishes. For example, in many states, it is possible to designate a health care proxy: someone who is authorized to make decisions for you in situations in which you are incapable of expressing your own wishes. A form from New York State is provided here as an example. Instead of filing a DNR with the hospital at the time of admission, an individual discusses his wishes regarding resuscitation and other treatments with a trusted individual who knows him well, and appoints that person to serve as his health care proxy in the event of incapacitation. In Pennsylvania, such an individual is known as a "health care agent," and one appoints him via a form granting durable health care power of attorney. Sample forms are available here.