Do-not-resuscitate orders are essential for guiding the care provided to hospitalized patients, according to background information in the article. Treatments like resuscitation may be inappropriate or may afford short-term benefits without achieving valued long-term goals. If DNR orders reflect patients' preferences and guide care that is consistent with these preferences, DNR orders can be considered indicators of the quality of health care at an institution, the authors suggest.
David S. Zingmond, M.D., Ph.D., and Neil S. Wenger, M.D., M.P.H., of The David Geffen School of Medicine at UCLA, Los Angeles, analyzed records from California hospitals to determine whether institutional factors were associated with the use of DNR orders. The researchers assessed the association between hospital characteristics, (size, profit status and academic status) and the use of a DNR order written within the first 24 hours of admission. The researchers also assessed whether there were regional differences in the use of DNR orders. Of approximately one and half million patients 50 or older admitted for acute care during 2000, the researchers included in their analysis 819,686 admissions at 386 California hospitals for 40 of the most common medical and surgical/procedural diagnoses-related groups (DRGs).
The researchers found that the percentage of DNR orders written within the first 24 hours of admission varied from two percent for patients aged 50-59 years to 17 percent for patients 80 years or older. The odds of having early DNR orders written were significantly lower in for-profit vs. private non-profit hospitals, were higher in the smallest vs. the largest hospitals, and were lower in academic vs. non-academic institutions. The rate of DNR order use varied by 10-fold depending on region with the highest rates in rural areas, the authors report.
"The initiation of end-of-life discussions and the implementation of DNR orders are important toward ensuring that patients receive care appropriate to their prognosis and preferences," the authors conclude. "Hospital characteristics appear to be associated with the use of DNR orders, even after accounting for differences in patient characteristics. This association reflects institutional culture, technological bent, and physician practice patterns."
(Arch Intern Med. 2005; 165:1705-1712. Available pre-embargo to the media at www.jamamedia.org.)
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