COMMUNICATING DO-NOT-RESUSCITATE ORDERS WITH A COMPUTER-BASED SYSTEM

Background: Do-not-resuscitate (DNR) orders for critically ill patient s are frequently miscommunicated between attending physicians, house s taff, and nurses. A computer-based system was developed to improve the communication of a procedure-specific DNR order form. Methods: Concor dance of understanding of patients' DNR status was measured with the u se of unstructured DNR orders (period 1), procedure-specific DNR order forms (period 2), and procedure-specific DNR order forms administered with a computer-based communication system (period 3). The 3 componen ts of the DNR order assessed were (1) the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld. Results: For the 147 patients, the computer-based syst em in period 3 (n = 71) improved concordance for attending physicians and nurses or residents for all 3 of the DNR components compared with period 1 (n = 40) and some of the DNR components compared with period 2 (n = 36). Concordance was ''substantial'' or ''almost perfect'' as m easured by the kappa statistic during period 3. The proportion of agre ement for the composite of all 3 components of the DNR order increased during each period (P<.001, period 3 vs period 1). Overall agreement be between all caregivers for the composite DNR order also improved fr om period 1 (22.2%) to period 2 (47.8%) and period 3 (61.9%; P<.001 vs period 1). Errors in order entry were detected by physicians because of the computer system and corrected in 9.9% of DNR orders in period 3 . Progress note documentation of DNR status did not improve during per iod 3. The procedures of period 3 were considered acceptable by the ph ysician and nursing staff. Conclusion: A computer-based system combine d with a procedure-specific DNR order form improves communication of p atients' DNR status in a critical care setting.