DO-NOT-RESUSCITATE ORDERS IN INTENSIVE-CARE UNITS - CURRENT PRACTICESAND RECENT CHANGES

Objectives.-To describe the characteristics of patients with do-not-re suscitate (DNR) orders and the frequency and timing of these orders in a representative sample of intensive care units (ICUs) and to compare practices from 1980 to 1990. Design.-Prospective inception cohort. Se tting.-A total of 42 ICUs in 40 US hospitals with 200 or more beds; 26 randomly selected hospitals and 14 large, tertiary care hospitals tha t volunteered to be studied. Participants.-A consecutive sample of 17 440 ICU admissions from 1988 to 1990.Measurements.-Patient demographic characteristics, comorbid conditions, disease, and physiological abno rmalities. Main Outcome Measures.-Frequency and timing of DN R orders; ICU resource use before and after DNR orders; and patients' hospital and ICU discharge status. Results.-Physicians wrote DNR orders for 157 7 ICU admissions (9%) (hospital range, 1.5% to 22%). Patients with ICU DNR orders were older, more functionally impaired, had more comorbid illness, a higher severity of illness, and required the usp of more IC U resources compared with patients without DNR orders. Compared with d ata from a similar survey from 1979 to 1982, ICU DNR orders were more frequent in 1988 to 1990 (9% vs 5.4%; P<.001) and preceded 60% of all in-unit deaths compared with only 39% in 1979 to 1982 (P<.001). Do-not -resuscitate orders were written sooner (for 3.6% vs 2.0% of patients on day 1 in the ICU) and patients with DNR orders remained in the ICU longer in 1988 to 1990 (2.8 vs 1.4 days) than in 1979 to 1982, and had lower ICU and hospital mortality rates (64% vs 74%, P<.001; and 85% v s 94%, P<.001). Conclusions.-Over the last decade physicians and patie nts' families set limits earlier and more frequently in cases likely t o have poor outcomes. We attribute this change to a greater dialogue a bout setting limits to care and a greater knowledge of treatment outco mes among physicians and families. These changes in practice preceded implementation of the Patient Self-determination Act, designed to ensu re patient autonomy for decisions about life-sustaining therapy.