Factors Associated with Do-Not-Resuscitate Orders: Patients' Preferences, Prognoses, and Physicians' Judgments

Rosemarie B. Hakim, Joan Teno, Frank E. Harrell, William A. Knaus, Neil Wenger, Russell S. Phillips, Peter Layde, Robert Califf, Alfred F. Connors, Joanne Lynn

Research output: Contribution to journalArticle

225 Citations (Scopus)

Abstract

Background: Medical treatment decisions should be based on the preferences of informed patients or their proxies and on the expected outcomes of treatment. Because seriously ill patients are at risk for cardiac arrest, examination of do-not-resuscitate (DNR) practices affecting them provides useful insights into the associations between various factors and medical decision making. Objective: To examine the association between patients' preferences for resuscitation (along with other patient and physician characteristics) and the frequency and timing of DNR orders. Design: Prospective cohort study. Setting: 5 teaching hospitals. Patients: 6802 seriously ill hospitalized patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) between 1989 and 1994. Measurements: Patients and their surrogates were interviewed about patients' cardiopulmonary resuscitation preferences, medical records were reviewed to determine disease severity, and a multivariable regression model was constructed to predict the time to the first DNR order. Results: The patients' preference for cardiopulmonary resuscitation was the most important predictor of the timing of DNR orders, but only 52% of patients who preferred not to be resuscitated actually had DNR orders written. The probability of surviving for 2 months was the next most important predictor of the timing of DNR orders. Although DNR orders were not linearly related to the probability of surviving for 2 months, they were written earlier and more frequently for patients with a 50% or lower probability of surviving for 2 months. Orders were written more quickly for patients older than 75 years of age, regardless of prognosis. After adjustment for these and other influential patient characteristics, the use and timing of DNR orders varied significantly among physician specialties and among hospitals. Conclusions: Patients' preferences and short-term prognoses are associated with the timing of DNR orders. However, the substantial variation seen among hospital sites and among physician specialties suggests that there is room for improvement. In this study, DNR orders were written earlier for patients older than 75 years of age, regardless of prognosis. This finding suggests that physicians may be using age in a way that is inconsistent with the reported association between age and survival. The process for making decisions about DNR orders needs to be improved if such orders are to routinely and accurately reflect patients' preferences and probable outcomes.

Original languageEnglish (US)
Pages (from-to)284-293
Number of pages10
JournalAnnals of internal medicine
Volume125
Issue number4
DOIs
StatePublished - Aug 15 1996
Externally publishedYes

Fingerprint

Resuscitation Orders
Patient Preference
Physicians
Cardiopulmonary Resuscitation
Proxy
Heart Arrest
Resuscitation
Teaching Hospitals
Medical Records
Decision Making
Cohort Studies

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Factors Associated with Do-Not-Resuscitate Orders : Patients' Preferences, Prognoses, and Physicians' Judgments. / Hakim, Rosemarie B.; Teno, Joan; Harrell, Frank E.; Knaus, William A.; Wenger, Neil; Phillips, Russell S.; Layde, Peter; Califf, Robert; Connors, Alfred F.; Lynn, Joanne.

In: Annals of internal medicine, Vol. 125, No. 4, 15.08.1996, p. 284-293.

Research output: Contribution to journalArticle

Hakim, RB, Teno, J, Harrell, FE, Knaus, WA, Wenger, N, Phillips, RS, Layde, P, Califf, R, Connors, AF & Lynn, J 1996, 'Factors Associated with Do-Not-Resuscitate Orders: Patients' Preferences, Prognoses, and Physicians' Judgments', Annals of internal medicine, vol. 125, no. 4, pp. 284-293. https://doi.org/10.7326/0003-4819-125-4-199608150-00005
Hakim, Rosemarie B. ; Teno, Joan ; Harrell, Frank E. ; Knaus, William A. ; Wenger, Neil ; Phillips, Russell S. ; Layde, Peter ; Califf, Robert ; Connors, Alfred F. ; Lynn, Joanne. / Factors Associated with Do-Not-Resuscitate Orders : Patients' Preferences, Prognoses, and Physicians' Judgments. In: Annals of internal medicine. 1996 ; Vol. 125, No. 4. pp. 284-293.
@article{ebe2465759ce40949380f2ede51ff2a4,
title = "Factors Associated with Do-Not-Resuscitate Orders: Patients' Preferences, Prognoses, and Physicians' Judgments",
abstract = "Background: Medical treatment decisions should be based on the preferences of informed patients or their proxies and on the expected outcomes of treatment. Because seriously ill patients are at risk for cardiac arrest, examination of do-not-resuscitate (DNR) practices affecting them provides useful insights into the associations between various factors and medical decision making. Objective: To examine the association between patients' preferences for resuscitation (along with other patient and physician characteristics) and the frequency and timing of DNR orders. Design: Prospective cohort study. Setting: 5 teaching hospitals. Patients: 6802 seriously ill hospitalized patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) between 1989 and 1994. Measurements: Patients and their surrogates were interviewed about patients' cardiopulmonary resuscitation preferences, medical records were reviewed to determine disease severity, and a multivariable regression model was constructed to predict the time to the first DNR order. Results: The patients' preference for cardiopulmonary resuscitation was the most important predictor of the timing of DNR orders, but only 52{\%} of patients who preferred not to be resuscitated actually had DNR orders written. The probability of surviving for 2 months was the next most important predictor of the timing of DNR orders. Although DNR orders were not linearly related to the probability of surviving for 2 months, they were written earlier and more frequently for patients with a 50{\%} or lower probability of surviving for 2 months. Orders were written more quickly for patients older than 75 years of age, regardless of prognosis. After adjustment for these and other influential patient characteristics, the use and timing of DNR orders varied significantly among physician specialties and among hospitals. Conclusions: Patients' preferences and short-term prognoses are associated with the timing of DNR orders. However, the substantial variation seen among hospital sites and among physician specialties suggests that there is room for improvement. In this study, DNR orders were written earlier for patients older than 75 years of age, regardless of prognosis. This finding suggests that physicians may be using age in a way that is inconsistent with the reported association between age and survival. The process for making decisions about DNR orders needs to be improved if such orders are to routinely and accurately reflect patients' preferences and probable outcomes.",
author = "Hakim, {Rosemarie B.} and Joan Teno and Harrell, {Frank E.} and Knaus, {William A.} and Neil Wenger and Phillips, {Russell S.} and Peter Layde and Robert Califf and Connors, {Alfred F.} and Joanne Lynn",
year = "1996",
month = "8",
day = "15",
doi = "10.7326/0003-4819-125-4-199608150-00005",
language = "English (US)",
volume = "125",
pages = "284--293",
journal = "Annals of Internal Medicine",
issn = "0003-4819",
publisher = "American College of Physicians",
number = "4",

}

TY - JOUR

T1 - Factors Associated with Do-Not-Resuscitate Orders

T2 - Patients' Preferences, Prognoses, and Physicians' Judgments

AU - Hakim, Rosemarie B.

AU - Teno, Joan

AU - Harrell, Frank E.

AU - Knaus, William A.

AU - Wenger, Neil

AU - Phillips, Russell S.

AU - Layde, Peter

AU - Califf, Robert

AU - Connors, Alfred F.

AU - Lynn, Joanne

PY - 1996/8/15

Y1 - 1996/8/15

N2 - Background: Medical treatment decisions should be based on the preferences of informed patients or their proxies and on the expected outcomes of treatment. Because seriously ill patients are at risk for cardiac arrest, examination of do-not-resuscitate (DNR) practices affecting them provides useful insights into the associations between various factors and medical decision making. Objective: To examine the association between patients' preferences for resuscitation (along with other patient and physician characteristics) and the frequency and timing of DNR orders. Design: Prospective cohort study. Setting: 5 teaching hospitals. Patients: 6802 seriously ill hospitalized patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) between 1989 and 1994. Measurements: Patients and their surrogates were interviewed about patients' cardiopulmonary resuscitation preferences, medical records were reviewed to determine disease severity, and a multivariable regression model was constructed to predict the time to the first DNR order. Results: The patients' preference for cardiopulmonary resuscitation was the most important predictor of the timing of DNR orders, but only 52% of patients who preferred not to be resuscitated actually had DNR orders written. The probability of surviving for 2 months was the next most important predictor of the timing of DNR orders. Although DNR orders were not linearly related to the probability of surviving for 2 months, they were written earlier and more frequently for patients with a 50% or lower probability of surviving for 2 months. Orders were written more quickly for patients older than 75 years of age, regardless of prognosis. After adjustment for these and other influential patient characteristics, the use and timing of DNR orders varied significantly among physician specialties and among hospitals. Conclusions: Patients' preferences and short-term prognoses are associated with the timing of DNR orders. However, the substantial variation seen among hospital sites and among physician specialties suggests that there is room for improvement. In this study, DNR orders were written earlier for patients older than 75 years of age, regardless of prognosis. This finding suggests that physicians may be using age in a way that is inconsistent with the reported association between age and survival. The process for making decisions about DNR orders needs to be improved if such orders are to routinely and accurately reflect patients' preferences and probable outcomes.

AB - Background: Medical treatment decisions should be based on the preferences of informed patients or their proxies and on the expected outcomes of treatment. Because seriously ill patients are at risk for cardiac arrest, examination of do-not-resuscitate (DNR) practices affecting them provides useful insights into the associations between various factors and medical decision making. Objective: To examine the association between patients' preferences for resuscitation (along with other patient and physician characteristics) and the frequency and timing of DNR orders. Design: Prospective cohort study. Setting: 5 teaching hospitals. Patients: 6802 seriously ill hospitalized patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) between 1989 and 1994. Measurements: Patients and their surrogates were interviewed about patients' cardiopulmonary resuscitation preferences, medical records were reviewed to determine disease severity, and a multivariable regression model was constructed to predict the time to the first DNR order. Results: The patients' preference for cardiopulmonary resuscitation was the most important predictor of the timing of DNR orders, but only 52% of patients who preferred not to be resuscitated actually had DNR orders written. The probability of surviving for 2 months was the next most important predictor of the timing of DNR orders. Although DNR orders were not linearly related to the probability of surviving for 2 months, they were written earlier and more frequently for patients with a 50% or lower probability of surviving for 2 months. Orders were written more quickly for patients older than 75 years of age, regardless of prognosis. After adjustment for these and other influential patient characteristics, the use and timing of DNR orders varied significantly among physician specialties and among hospitals. Conclusions: Patients' preferences and short-term prognoses are associated with the timing of DNR orders. However, the substantial variation seen among hospital sites and among physician specialties suggests that there is room for improvement. In this study, DNR orders were written earlier for patients older than 75 years of age, regardless of prognosis. This finding suggests that physicians may be using age in a way that is inconsistent with the reported association between age and survival. The process for making decisions about DNR orders needs to be improved if such orders are to routinely and accurately reflect patients' preferences and probable outcomes.

UR - http://www.scopus.com/inward/record.url?scp=0000251207&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0000251207&partnerID=8YFLogxK

U2 - 10.7326/0003-4819-125-4-199608150-00005

DO - 10.7326/0003-4819-125-4-199608150-00005

M3 - Article

C2 - 8678391

AN - SCOPUS:0000251207

VL - 125

SP - 284

EP - 293

JO - Annals of Internal Medicine

JF - Annals of Internal Medicine

SN - 0003-4819

IS - 4

ER -