A patient coming to a hospital emergency room with a “do not resuscitate” (DNR) order in place is at a significant risk of dying within 28 days of being admitted, according to an international study led by researchers at Ben-Gurion University of the Negev.
While this might sound initially logical – isn’t that the intention of DNR? – it’s actually a misunderstanding with critical results, say the researchers.
The practical meaning of a DNR is not to attempt CPR in certain circumstances. But the researchers theorize that ICU doctors are interpreting the DNR more broadly to mean fewer treatments and medicines.
In particular, the authors of the paper, which was published in Critical Care Medicine, found that patients with a DNR received less mechanical ventilation, fewer radiological investigations and fewer prescribed medications. Other studies have shown that DNR patients receive fewer heart-failure interventions as well.
The study, headed by Dr. Lior Fuchs, a senior physician in the medical intensive care unit at Soroka University Medical Center, and Prof. Victor Novack, a professor of internal medicine in BGU’s Faculty of Health Sciences, looked at 19,007 patients who entered the ICU between 2001 and 2008 at Beth Israel Deaconess Medical Center in Boston, Massachusetts.
Of those, 1,239 had a DNR order on the first day of their ICU admission and survived the first 48 hours. The authors compared their treatment to 2,402 similar patients (age, type of ICU and 28-day probability of death) who did not have a DNR order on day one.
“Looking at 28-day mortality, the rates were significantly higher in the DNR group (33.9 percent vs. 18.4 percent),” says BGU’s Novack. “Moreover, even within the group with a low probability of death, patients with DNR orders had five-fold increases in 28-day mortality from 3 percent to 17 percent.”
Specific patient groups that were especially vulnerable: women, surgical, mechanically ventilated and cancer patients.
The researchers believe the problem lies with doctors confusing DNR orders and patients’ desires for end-of-life care, resulting in less inclination to intervene in life-threatening situations. The team recommends clarifying such matters before treatment.
Also participating in the study were staff from Harvard Medical School, MIT, the University of Chicago, Sir Charles Gairdner Hospital in Western Australia and the Agency for Science, Technology and Research of Singapore.