Unilateral Do-Not-Attempt Resuscitation Orders at the Massachusetts General Hospital

The American Thoracic Society International Conference begins this week in San Diego.  There are a number of sessions and posters related to end-of-life ethics.  This one seemed particularly interesting.

Unilateral Do-Not-Attempt Resuscitation Orders In A Large Academic Hospital

A. Courtwright, MD, PhD

S. Brackett, RN, BS, CCRN

E. Robinson, RN, PhD



RATIONALE:

Unilateral Do-Not-Resuscitate (DNR) orders are a specific type of medical futility decision in which clinicians withhold advanced cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest despite objections of patients or their surrogates.



There is little information on how often and to whom unilateral DNR orders are applied. The ethics committee at Massachusetts General Hospital has had a unilateral DNR policy since 2006. We investigated the incidence, sociodemographic and clinical predictors, and outcomes of patients with unilateral DNR orders.



METHODS:

We reviewed all ethics committee consults that involved disagreement between health care providers and patients/surrogates over intensity of treatment, including DNR status. We used bivariate and multivariate statistics to compare sociodemographic and clinic data from cases in which unilateral DNR was and was not recommended. We recorded whether this recommendation was actually followed and patient disposition following consultation.



RESULTS:

There were 147 cases of conflict over intensity of treatment and DNR status. Of these, the ethics committee recommended unilateral DNR 35% of the time and this recommendation was followed in 83% of cases. 



Neither age (70±3.9 years versus 73±2.5 years, p=0.43) nor female sex (38% versus 50%, p=0.63) was associated with unilateral DNR recommendation. Patients for whom unilateral DNR was recommended were more likely to be non-white (48% versus 26%, p=0.05). Measures of functional status prior to admission, including number of medical comorbidities (3.8±0.28 versus 3.2±0.22, p=0.08) or full or partial dependence in activities of daily living (62% versus 50%, p=0.36), were not associated with unilateral DNR recommendation. Patients for whom unilateral DNR was recommended were more likely to have conditions judged to be endstage rather than potentially reversible (62% versus 41%, p=0.05). Patients for whom unilateral DNR was actually ordered were more likely to die during their hospitalization (79% versus 48%, p=0.01).



CONCLUSION:

Patient age, gender, and functional status prior to admission are not associated with an ethics committee’s decision to recommend a unilateral DNR order. Non-white patients and patients judged to have end stage conditions are more likely to have a unilateral DNR order recommended. Patients who are actually made DNR unilaterally are more likely to die in the hospital.