Do-not-resuscitate (DNR) orders often lead to increased death rates and negative health outcomes, a recent study found.
Jonathan Baktari, M.D., president and CEO of medical lab e7 Health, conducted a literature review of 10 existing peer-reviewed studies on the subject. He did so after coming to the surprising conclusion that no such collection of data exists, he told Fierce Healthcare. His review does not include every study on the topic.
The results would be enough to pull a pharmaceutical drug off the shelves, Baktari believes. DNR is “not given the same critical evaluation that we give to a potential surgery or procedure or diagnostic test or medication,” he said. Baktari emphasized that this is not about DNR being used inappropriately, but rather the subsequent treatment patients receive when they have a DNR order. He acknowledged DNR can be an important tool to empower patients and alleviate potential suffering.
Several studies have found that patients with DNRs have higher death rates for reasons unrelated to the DNR order. One study found that more than 13% of surgical patients with DNR in place died within 30 days of their operation, compared to only 5.6% of those without DNR. This disparity was even starker among vascular surgery patients: Those with a DNR were more likely (9%) to experience graft failure compared to those without (2%), and 35% died within 30 days of surgery compared to 14% of those without a DNR.
Among stroke patients, almost half of those with a DNR designated within the first 24 hours of hospitalization died at the hospital, compared to only 13% who survived.
A DNR does not mean that the patient wants to receive any less care or treatment than a patient without the order, Baktari noted in the study. However, “in many hospitals, DNR may as well stand for DNT (do not treat),” he wrote. When examining cancer patient perception, a study found 11% of clinicians thought a DNR order meant “comfort measures.”
Other studies found that a DNR order led to less care overall, including getting blood samples, central line replacements and blood transfusions. Resident physicians were also less likely to provide treatment to DNR patients like dialysis or intensive care transfers despite not being told to abstain from those measures by the patient or their family, one study found.
“No single national DNR standard exists for healthcare providers, and this variation means that even within the same city, patients at different hospitals can receive wildly different care,” Baktari noted in the study. Baktari pointed to several states that have a portable medical order program in place, which is meant to help patients offer details about exactly what treatments they want or don’t want. It is meant to supplement DNR orders.
While there is training on the benefits of DNR in medical school, there is little discussion about the potential negative ramifications, Baktari said. This review is “irrefutable” that some sort of culture or mindset about DNR is pervasive across all types of clinical roles in the healthcare setting. “It would be difficult to have a retort,” he said. To help combat these concerning trends, Baktari believes acknowledging there is a problem and becoming educated on how to fix it is key. Every clinician needs to understand that a DNR order does not mean a patient wants less medical care—and there should be a standardized set of criteria for using DNRs across the healthcare system.
“There are ways to make DNR not so subjective,” he said.