Hospitals respond differently to ‘do not resuscitate’

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Hospitals vary widely in the scope of invasive and organ-supportive interventions that they provide to patients with do-not-resuscitate (DNR) orders, report researchers.

Patients with these 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.”

For the study in the journal Health Services Research, researchers analyzed claims data from California hospitals, and 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 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 among DNR patients at hospitals with higher rates of DNR orders.

The 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.

Incomplete forms lead to unwanted end-of-life care

“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 researchers write.

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, these orders may be broadly interpreted to suggest limiting a wide range of life-sustaining interventions, such as mechanical ventilation or hemodialysis.

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 also 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.

Allan Walkey, assistant professor of medicine at Boston University School of Medicine and a researcher with the Evans Center for Implementation and Improvement Sciences, led the study. Coauthors are from Boston University School of Public Health, the University of Michigan, and Tufts University School of Medicine.

Source: Boston University