Racial variation in the use of do-not-resuscitate orders

OBJECTIVE: To compare the use of do-not-resuscitate (DNR) orders in African -American and white patients using a large, multisite, community-based samp le. MEASUREMENTS: Our sample included 90,821 consecutive admissions to 30 hospi tals in a large metropolitan region with six nonsurgical conditions from 19 93 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate ris k-adjustment models with excellent discrimination (receiver-operating chara cteristic curve areas, 0.82-0.88), Multiple logistic regression analysis wa s used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and ol:her covariates. MAIN RESULTS: In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%: p <.001), Rates of orders were also lower (p <.001) among African Americans in analyses stratified by age, gender, d iagnosis,, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR. order remained lower (p <.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointesti nal hemorrhage, Results were similar in analyses limited to orders written by the first, second, or seventh hospital day, Finally, among patients with DNR orders, African Americans were less likely to have orders written on t he first hospital day and more likely to have orders written on subsequent days. CONCLUSIONS: The use of DNR orders was substantially lower in African Ameri cans than in whites, even after adjusting for severity of illness and other covariates, Identification of factors underlying such differences will imp rove our understanding of the degree to which expectations for care differ in African American and white patients.