DO-NOT-RESUSCITATE DECISIONS IN THE MEDICAL ICU - COMPARING PHYSICIANAND NURSE OPINIONS

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.