Do-not-resuscitate orders linked to increased death rates, study finds

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Do-not-resuscitate (DNR) orders, meant to reduce needless suffering, often lead to increased death rates, worse medical care and negative health outcomes, according to a study by e7Health.

The report, which analyzed 10 peer-reviewed studies, including those from the Centers for Disease Control and Prevention, American Heart Association and Harvard Medical School, found DNR often has become a self-fulfilling prophecy, and doubled the death rate for surgical patients despite fewer complications. 

In addition, patients who signed DNRs received less care not related to heroic measures or resuscitation.

In one study, geriatric DNR patients were seven percentage points less likely to have blood cultures drawn, 12 percentage points less likely to have a central IV line placed, and 12 percentage points less likely to receive a blood transfusion.

The analysis also indicated use of DNR early in a health crisis can be deadly, pointing to a California study of cardiac arrest patients.

In that study, patients who signed a DNR within 24 hours -- before a prognosis can be made – survived 5.2% of the time, compared to 21.6% of non-DNR patients.

Among the report's more alarming findings were those pulled from a Harvard Medical School study of patients undergoing elective procedures, which found DNR doubled the death rate for surgical patients.

Meanwhile, a California study found almost half of stroke victims who were designated DNR within the first 24 hours died in the hospital. 

WHY THIS MATTERS

Although DRN does not mean do not treat, that appears to be what happens in many hospitals across the country, with medical research studies increasingly connecting DNR orders with higher death rates.

While patients with a DNR or DNI are more likely to be patients nearing the end of their life and may be suffering from a serious illness, evidence suggests the mere presence of the DNR or DNI increases death rates, unrelated to a disease or trauma.

Even when it comes to overall patient care, those levels drop for patients who signed DNR or DNI orders and are less likely to have blood cultures drawn, less likely to have a central IV line placed, and less likely to receive a blood transfusion.

THE LARGER TREND

The report pointed out no single national DNR standard exists for healthcare providers, and variations in definition exist even within the same city, which means patients at different hospitals can receive wildly different care.

Many states are currently in the process of adopting portable medical order programs (POLST), which can serve as supplements to advance directives like DNR/DNI. Six states have already adopted the form, and dozens more are considering them or working to adopt them.

The e7Health report urged Massachusetts patients to consider their unique circumstance and do research when deciding whether to sign a DNR order.

ON THE RECORD 

"Every person wants and deserves to have their medical wishes honored, especially when it comes to experiencing a traumatic and potentially painful medical intervention like CPR or intubation," the report concluded. "While the presence of DNR and DNI orders have helped many people make their own medical decisions, the reality is not black and white. At a minimum, individuals and their loved ones should have thorough discussions with themselves and their medical care providers about exactly what might happen if they sign a DNR or DNI."