Resource utilization and end‐of‐life care in a US hospital following medical emergency team‐implemented do not resuscitate orders
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BACKGROUND Medical emergency teams frequently implement do not resuscitate orders, but little is known about end‐of‐life care in this population. OBJECTIVE To examine resource utilization and end‐of‐life care following medical emergency team‐implemented do not resuscitate orders. DESIGN Retrospective review. SETTING Single, tertiary care center. PATIENTS Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS None. RESULTS We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team‐implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team‐implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS Despite high mortality, patients with medical emergency team‐implemented do not resuscitate orders had a relatively low utilization of end‐of‐life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end‐of‐life care. Journal of Hospital Medicine 2014;9:372–378. © 2014 Society of Hospital MedicineKeywords:
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Do-not-resuscitate (DNR) orders are commonly found in treatment plans for patients near the end of life. Orders for partial resuscitation (eg, "do not intubate") have evolved from DNR orders. Although the ethics of DNR orders have been widely examined in the medical literature, little has been written about the ethics of partial resuscitation. This article explores the ethical implications of partial DNR orders and identifies the need to develop care plans addressing life-threatening conditions for patients with DNR orders.
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Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders.Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling.At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036-4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989-89.786; P=.008). Both arms issued DNR orders close to death (median, 5-6 days before death).Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846.
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In 1988, a new do-not-resuscitate policy aimed at assisting professional staff, nurses, patients, and families in end-of-life choices replaced the existing policy at The Cleveland Clinic Foundation. We conducted a retrospective chart review to examine the effects of the new policy on length of stay. Data were collected on demographics, clinical information, length of stay, and the frequency of do-not-resuscitate orders for expired Medicare patients in 1987 (n = 125) and 1989 (n = 135). Length of stay for patients who received a do-not-resuscitate order was significantly reduced in 1989 compared with 1987, partly because the orders were issued earlier in patients' stays in 1989. The number of days from writing the order until death did not change significantly from 1987 to 1989. We conclude that a well-defined do-not-resuscitate policy can reduce length of stay.
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Children's Hospital, Department of Anesthesia, Multidisciplinary Intensive Care Unit, 300 Longwood Avenue, Boston, MA 02115
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We reviewed the records of 274 consecutive deaths at the Milton S. Hershey Medical Center, Hershey, Pa, occurring through May 1988 to examine the approach of physicians, patients, and families in making the decision to invoke the "do-not-resuscitate" order. Of these 274 patients who died, 171 (62%) had do-not-resuscitate orders. Of these 171 patients, 86 (50%) were judged fully mentally competent on admission to the hospital; 44 (51%) of these 86 fully competent patients were included in the decision to withhold resuscitative efforts. In the remainder, the family was usually involved in the decision without input from the patient. Only 6 patients (4%) were admitted to the hospital with a preexisting do-not-resuscitate order. For the remainder, the do-not-resuscitate order was written a mean of 8.5 days following admission and 3.3 days before death. Documentation of this order with a specific progress note was universal. The principle reason cited for a do-not-resuscitate order was the presence of irreversible terminal disease in 52% and an unacceptable quality of life in 33%. When considered separately, patients with a principle diagnosis of malignant neoplasm had a do-not-resuscitate order written 80% of the time. Of 88 such patients, 48 (55%) were fully competent at admission. In turn, 36 (75%) of these patients participated in the do-not-resuscitate decision. Nursing activities were quantified for the 24 hours preceding and the 24 hours following the do-not-resuscitate order. No difference could be found comparing these two periods whether the comparison was made on the general hospital ward or in the intensive care unit.(ABSTRACT TRUNCATED AT 250 WORDS)
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We applaud Hebert and Selby[1][1] for examining the difficulties of responding to iatrogenic or potentially readily reversible critical incidents in patients with a do-not-resuscitate order. Several Canadian health authorities have already replaced do-not-resuscitate orders with more nuanced medical
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• We reviewed the records of 274 consecutive deaths at the Milton S. Hershey Medical Center, Hershey, Pa, occurring through May 1988 to examine the approach of physicians, patients, and families in making the decision to invoke the "do-not-resuscitate" order. Of these 274 patients who died, 171 (62%) had do-not-resuscitate orders. Of these 171 patients, 86 (50%) were judged fully mentally competent on admission to the hospital; 44 (51%) of these 86 fully competent patients were included in the decision to withhold resuscitative efforts. In the remainder, the family was usually involved in the decision without input from the patient. Only 6 patients (4%) were admitted to the hospital with a preexisting do-not-resuscitate order. For the remainder, the do-not-resuscitate order was written a mean of 8.5 days following admission and 3.3 days before death. Documentation of this order with a specific progress note was universal. The principle reason cited for a do-not-resuscitate order was the presence of irreversible terminal disease in 52% and an unacceptable quality of life in 33%. When considered separately, patients with a principle diagnosis of malignant neoplasm had a do-not-resuscitate order written 80% of the time. Of 88 such patients, 48 (55%) were fully competent at admission. In turn, 36 (75%) of these patients participated in the do-not-resuscitate decision. Nursing activities were quantified for the 24 hours preceding and the 24 hours following the do-not-resuscitate order. No difference could be found comparing these two periods whether the comparison was made on the general hospital ward or in the intensive care unit. We conclude that some progress is being made as a reasonable percentage of mentally competent patients dying in this center are included in the decision to limit their care at the time of death. However, this decision is only rarely considered until late in the course of most patients' terminal hospitalization. A do-not-resuscitate order apparently does not result in a reduction in the quantity of nursing activity for patients as they die. (Arch Intern Med. 1990;150:1057-1060)
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