Impediments to writing do-not-resuscitate orders

Background: Physicians are frequently unaware of their patients' desires re garding end-of-life care. Consequently, opportunities to implement do-not-r esuscitate (DNR) orders are often missed. Objective: To determine the reasons attending physicians do not write DNR o rders when patients face increased mortality. Methods: Over 4 months, the medical records of all inpatients on the Genera l Medicine Sen ice were reviewed at the time of discharge to identify patie nts with conditions predicting increased mortality. These cases were presen ted to a 5-member panel who decided if a DNR order was indicated. Reasons f or missing DNR orders were discussed with the attending physicians. Results: Of 613 consecutive admissions, the panel identified 149 patients ( 24%) for whom DNR orders were indicated. In 88 (59%) of these, DNR orders w ere absent. The lack of a DNR order did not correlate with age (P = .95), s ex (P = .61), or race (P = .80). The attending physicians' explanations for not writing DNR orders in these 88 cases included the belief that the pati ent was not in imminent danger of death (n = 49 [56%]), the belief that the primary physician should discuss DNR issues (n = 43 [49%]), and the lack o f an appropriate opportunity to discuss end-of-life issues (n = 38 [43%]). In 11 (12%) of the 88 cases, patients or their families did not accept the recommendation for a DNR order. No physicians expressed concerns regarding the morality of DNR orders, discomfort discussing end-of-life issues, or th e threat of litigation as reasons for not writing a DNR order. Conclusions: Limitations in the extent and depth of the physician-patient r elationship appear to be the most frequent impediments to writing DNR order s in our institution.