Study objective: To determine how soon after admission to a medical IC
U physicians and nurses decide that attempts at resuscitation are inap
propriate and how frequently physicians and nurses disagree about do-n
ot-resuscitate (DNR) decisions. Design: Prospective, opinion survey of
care providers. Setting: Ten-bed adult medical ICU in a university-af
filiated tertiary care referral hospital. Patients: Consecutive adult
medical ICU admissions. Interventions: Over 10 months, physicians and
nurses were surveyed independently every day regarding their opinions
about DNR issues on each patient in the ICU. Measurements: ICU day whe
n DNR order was deemed appropriate by either physicians or nurses. Res
ults: Of 368 consecutive admissions, 84 (23%) patients were designated
DNR during their ICU stay. In 6 of these 84 cases (7%), the responsib
le nurse did not agree that DNR orders were appropriate. In the remain
ing 78 patients designated DNR, the median time for physicians to reco
mmend DNR (median, 1 day; range, 0 to 22 days) was not significantly d
ifferent from the median time for nurses (median, 1 day; range, 0 to 1
3 days); (p=0.45). For the 284 patients not designated DNR, physicians
and nurses both believed DNR was appropriate in 14 cases (5%), but a
DNR order was not written five times (2%) because there was not time t
o do so and nine times (3%) because patient or family did not concur.
Physicians and nurses disagreed about a DNR recommendation in 33 of th
e 284 patients not designated DNR (12%), Physicians were more likely t
o believe that DNR was appropriate than were nurses (p<0.0005), with p
hysicians alone recommending DNR 29 times (10%) and nurses alone favor
ing DNR in four cases (1%). Conclusions: At our institution, recogniti
on of DNR appropriateness by nurses and physicians occurs over a simil
ar time frame. However, physicians are more likely to recommend DNR in
cases of disagreement between nurses and physicians.