Are patients’ DNR orders overinterpreted?

They may be marker for less-aggressive care

A new study conducted by researchers at the Johns Hopkins University School of Medi-cine in Baltimore indicates that some physicians may be overinterpreting the do-not-resuscitate (DNR) orders that some patients opt for near the end of their lives. Aside from withholding cardiopulmonary resuscitation in the event of a cardiac arrest under DNRs, the study finds that some physicians also are refraining from using other kinds of life-saving procedures for patients who have DNRs.

"DNRs are supposed to be intended to allow patients to forego CPR after arresting," explains Mary Catherine Beach, MD, MPH, assistant professor at Johns Hopkins School of Medicine, and the study’s co-author. "Generally, patients who choose a DNR may also choose to forgo other life-savings measures, but the DNR was not intended for this purpose. During my medical training, I noticed that docs with DNRs on their patient would question doing other life-prolonging procedures as well."

Because patients can reasonably choose to forego CPR yet still wish to receive other life-sustaining or life-prolonging treatments, Beach became concerned that DNRs were being used as a surrogate marker for less-aggressive care, rather than as a specific instruction. This, in turn, led to the study, which appeared in the December issue of the Journal of the American Geriatrics Society. (The effect of do not resuscitate orders on physician decision-making. 2002; 50:12.)

The findings of the study appear to confirm Beach’s suspicions. The study reported responses from 241 physicians (352 attendings and 111 residents were surveyed, with a 52% response rate), describing three cases dealing with patients who had life-threatening illnesses. Some physicians were told the patients had DNRs, while some physicians were told the patients did not have DNRs.

"We designed a survey for all attending and resident physicians at a large urban academic facility," says Beach. "We presented three clinical vignettes in which otherwise identical patients did or did not have a DNR. This was followed by a series of 10 treatment options; the doctors were asked to rate whether they would agree the patients should have those treatments." In each of the three scenarios when a DNR order was present, the physicians were less likely to provide life-sustaining treatment for the hypothetical patient. "Some of these treatments actually have nothing to do with CPR," she notes.

Why would physicians react in this manner? "I think when someone sees a DNR, he thinks the patient is dying," Beach explains. "So when they ask themselves, Why should I do this colonoscopy?’ they’re really saying, Why subject someone who is dying to unnecessary pain and suffering?’" Of course, the patient may, in fact, want that colonoscopy. There are several ways to avoid such possible misunderstandings, she says:

• Physicians should openly discuss the goals of patient therapy with their patients.

"Go in and have a discussion of what the patient hopes to achieve," she advises. "You can then negotiate more specific treatment options, [and] have them noted in the chart and communicated to all involved in the patient’s care."

• Hospital policy should distinguish DNR from palliative care.

"Some hospital policies simply mention routine terminal care,’" notes Beach. "Some routine procedures are certainly not equated with DNR."

• Medical educators have to educate physicians in the skills needed to take on these discussions.

"Palliative care should be devoted to achieving a higher quality of life, as well as making these decisions," Beach asserts.

"Quality managers should review such cases with physicians and remind them that DNR orders do not mean don’t treat the patient,’" she says.

Need More Information?

For more information, contact:

  • Mary Catherine Beach, MD, MPH, Assistant Professor, Johns Hopkins University School of Medicine, 1830 E. Monument St., Room 8016, Baltimore, MD 21205. Telephone: (410) 614-1134.