Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment.

BACKGROUND: The relationship of do-not-resuscitate (DNR) orders to patient and hospital characteristics has not been well characterized.
METHODS: This observational study of a nationally representative sample of 14,008 Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture evaluated the relationship of DNR orders to patient sickness at admission, functional impairment, age, disease, race, gender, preadmission residence, insurance status, and hospital characteristics.
RESULTS: Of the 14,008 patients, DNR orders were assigned to 11.6%. Patients with greater sickness at admission and functional impairment received more DNR orders (P < .001) but even among patients in the sickest quartile (with a 65% chance of death within 180 days), only 31% received DNR orders. The DNR orders were assigned more often to older patients after adjustment for sickness at admission and functional impairment (P < .001), and DNR order rates differed by diagnosis (P < .001). After adjustment for patient and hospital characteristics, DNR orders were assigned more often to women and patients with dementia or incontinence and were assigned less often to black patients, patients with Medicaid insurance, and patients in rural hospitals.
CONCLUSIONS: Do-not-resuscitate orders are assigned more often to sicker patients but may be underused even among the most sick. Sickness at admission and functional impairment do not explain the increase in DNR orders with age or the disparity across diagnosis. Further evaluation is needed into whether variation in DNR order rates with age, diagnosis, race, gender, insurance status, and rural location represents differences in patient preferences or care compromising patient autonomy.