The 'Do not resuscitate' order. A profile of its changing use.

The "do not resuscitate" (DNR) order has wide-ranging ethical, legal, and economic implications. We reviewed the course of 244 patients who died during two three-month periods, in 1982 and 1986. We found that 68% of patients who died had a DNR order written, including 94% with malignancy and half of patients with cardiovascular disease. Most orders (61%) were written within three days of death, with 64% written on medical-surgical floors and 34% in critical care units. Even among patients under the age of 60 years, 57% had a DNR order written by the time of death. Ninety-one percent of DNR orders were written by attending physicians, with accompanying explanatory note in 84%. Documentation showed only 14% of patients but 77% of families being consulted. In 1983 a new two-level DNR order system defined two levels of intensity: "all but cardiopulmonary resuscitation" and "comfort measures only." Equal numbers of patients received each order in the 1986 sample. No patient was transferred to the critical care units after a DNR order had been written. The prevalence of DNR orders written for patients dying of cardiovascular disease increased from 27% to 64% over the four years. We conclude, from study of deaths in this representative community hospital, that an explicit DNR order is now the rule rather than the exception, but decisions are made late and involve family far more than the patient.