Variation Found Among Hospitals in Carrying out DNR Orders.
Hospitals vary widely in the scope of invasive and organ-supportive interventions provided to patients with DNR (do not resuscitate) orders, with high-DNR-rate facilities less likely to use invasive and organ-supportive interventions and more likely to use palliative care, according to a new study led by researchers from the School of Public Health and School of Medicine.
The study, in the journal Health Services Research, found that patients with DNR orders “may have considerably different experiences depending upon the hospital to which they are admitted, with ramifications for the reporting of hospital practices around wishes for life-sustaining treatments, measurement of practice variation, and hospital quality.”
The research team, which analyzed claims data from California hospitals, found that hospitals with higher rates of DNR orders tended to use a “less invasive, more palliative approach” among patients with such orders—contrary to the theory that lower-DNR hospitals might tend to enforce DNR orders more strictly.
While there was minimal variation between hospitals in the use of CPR among patients with DNR orders, other organ-supportive interventions, such as mechanical ventilation and dialysis, were less likely to be used among DNR patients at hospitals with higher rates of DNR orders.
The authors said their findings of fewer invasive interventions at high-DNR hospitals likely arise from “different hospital practices and local cultural norms for discussing, eliciting, and documenting patient wishes” regarding life-sustaining treatments.
“Our findings suggest that studies should continue to explore how interactions between patient beliefs and physician practice styles drive measured variation in hospital DNR rates and the scope of therapies associated with DNR orders,” the authors said. They said that identifying and reporting the variation in DNR practices would produce greater transparency for patients, potentially allowing them to choose hospitals with practice patterns that “best align with their beliefs.”
In the strictest interpretation, DNR orders are meant to convey wishes of patients not to receive CPR during cardiac arrest. But in practice, DNR orders may be broadly interpreted to suggest limiting a wide range of life-sustaining interventions, such as mechanical ventilation or hemodialysis.
The authors noted that many patients with DNR orders receive organ-supportive therapies, short of CPR—indicating differences in how the orders are interpreted and enacted by clinicians.
The study found that, among patients without DNR orders, use of organ support interventions did not markedly differ between hospitals with low and high rates of DNR.
The study was led by Allan Walkey, assistant professor of medicine at MED and a researcher with the Evans Center for Implementation and Improvement Sciences. Co-authors include: Janice Weinberg, professor of biostatistics at SPH; Renda Soylemez Wiener, assistant professor of medicine at MED; Colin Cooke of the Institute for Healthcare Policy and Innovation, University of Michigan; and Peter Lindenauer of Baystate Medical Center, Tufts University School of Medicine.