Hospital do-not-resuscitate orders: why they have failed and how to fix them.
ABSTRACT Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.
- [Show abstract] [Hide abstract]
ABSTRACT: There is a paucity of data examining the epidemiology of recipients of multiple in-hospital cardiopulmonary resuscitation (CPR) attempts, and their outcomes. Data source: Nationwide Inpatient Sample, 2000 to 2009. Patient characteristics, survival to discharge, discharge disposition, and cost of hospitalization of patients who had 1 versus multiple (>1) CPR attempts were compared using bivariate and multivariate methods. Of 166,519 hospitalized CPR recipients, 3.4% had multiple CPR attempts. Compared with 1-time CPR recipients, those undergoing multiple CPR were younger (age <65 years; 37.3% vs 42.5%, respectively), more often nonwhite (34.2% vs 41.4%), and commonly treated in nonteaching hospitals (58.0% vs 64.5%; all P < 0.001). Survival to discharge decreased by >40% for each additional CPR attempt (23.4% vs 11.9%, and 6.7% for 1, 2, and ≥3 CPR attempts, respectively; P < 0.001). After multivariate adjustment, multiple CPR was independently associated with a lower survival to discharge (odds ratio: 0.41, 95% confidence interval: 0.37-0.44, P < 0.001). Recipients of multiple CPR were more likely to be discharged to destinations other than home (80.7% vs 70.1%, P < 0.001); 1 in 15 survivors of multiple CPR were discharged to hospice (6.8%), compared with 1 in 23 patients (4.3%) who had 1 CPR (P = 0.002). The average cost per day of hospitalization was higher for patients who had multiple CPR versus 1 CPR ($4484.60 vs $3581.40, P < 0.001). Recipients of multiple in-hospital CPR attempts are more likely to be younger, nonwhite, and treated in nonteaching hospitals. Survival to discharge is significantly worse, and the cost of hospitalization is considerably higher for these patients. Journal of Hospital Medicine 2013;. © 2013 Society of Hospital Medicine.Journal of Hospital Medicine 12/2013; · 1.40 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: PURPOSE: Discussing end-of-life care with patients is often considered taboo, and signing a do-not-resuscitate (DNR) order is difficult for most patients, especially in Chinese culture. This study investigated distributions and details related to the signing of DNR orders, as well as the completeness of various DNR order forms. METHODS: Retrospective chart reviews were performed. We screened all charts from a teaching hospital in Taiwan for patients who died of cancer during the period from January 2010 to December 2011. A total of 829 patient records were included in the analysis. The details of the DNR order forms were recorded. RESULTS: The DNR order signing rate was 99.8 %. The percentage of DNR orders signed by patients themselves (DNR-P) was 22.6 %, while the percentage of orders signed by surrogates (DNR-S) was 77.2 %. The percentage of signed DNR forms that were completely filled out was 78.4 %. The percentage of DNR-S forms that were completed was 81.7 %, while the percentage of DNR-P forms that were completely filled out was only 67.6 %. CONCLUSION: Almost all the cancer patients had a signed DNR order, but for the majority of them, the order was signed by a surrogate. Negative attitudes of discussing death from medical professionals and/or the family members of patients may account for the higher number of signed DNR-S orders than DNR-P orders. Moreover, early obtainment of signed DNR orders should be sought, as getting the orders earlier could promote the quality of end-of-life care, especially in non-oncology wards.Supportive Care in Cancer 05/2013; · 2.09 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. 19 selected RACFs in Victoria. 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.Supportive and Palliative Care 09/2013; 3(3):349-357.
Hospital Do-Not-Resuscitate Orders: Why They Have
Failed and How to Fix Them
Jacqueline K. Yuen, MD1, M. Carrington Reid, MD, PhD1, and Michael D. Fetters, MD, MPH, MA2
1Division of Geriatrics and Gerontology, Weill Medical College, Cornell University, New York, NY, USA;2Department of Family Medicine,
University of Michigan, Ann Arbor, MI, USA.
Do-not-resuscitate (DNR) orders have been in use in
hospitals nationwide for over 20 years. Nonetheless, as
currently implemented, they fail to adequately fulfill
their two intended purposes—to support patient auton-
omy and to prevent non-beneficial interventions. These
failures lead to serious consequences. Patients are
deprived of the opportunity to make informed decisions
regarding resuscitation, and CPR is performed on
patients who would have wanted it withheld or are
harmed by the procedure. This article highlights the
persistent problems with today’s use of inpatient DNR
orders, i.e., DNR discussions do not occur frequently
enough and occur too late in the course of patients’
illnesses to allow their participation in resuscitation
decisions. Furthermore, many physicians fail to provide
adequate information to allow patients or surrogates to
make informed decisions and inappropriately extrapo-
late DNR orders to limit other treatments. Because
these failings are primarily due to systemic factors that
result in deficient physician behaviors, we propose
strategies to target these factors including changing
the hospital culture, reforming hospital policies on DNR
discussions, mandating provider communication skills
training, and using financial incentives. These strate-
gies could help overcome existing barriers to proper
DNR discussions and align the use of DNR orders closer
to their intended purposes of supporting patient self-
determination and avoiding non-beneficial interven-
tions at the end of life.
KEY WORDS: do-not-resuscitate orders; informed consent; end-of-life
J Gen Intern Med (26)7:791–7
© Society of General Internal Medicine 2011
In 1960, Kouwenhoven and colleagues first introduced closed-
chest cardiac massage as an effective means of resuscitating
victims of cardiac arrest.1Soon after, the practice known as
cardiopulmonary resuscitation (CPR) became a routine emer-
gency procedure performed by any trained provider with a
presumption of patient consent to the procedure. Beginning in
the 1980s, however, studies showed that the average survival
rate to hospital discharge for all patients undergoing CPR in
the US was only 10-15%.2–4This rate has not measurably
improved over the last 20 years.5–9For patients with certain
diagnoses (e.g., metastatic cancers), survival rates are even
lower.2,4,7,10,11Furthermore, patients who were successfully
resuscitated often undergo aggressive treatment in the inten-
sive care unit and suffer complications including rib fractures,
permanent neurological deficits, and impaired functional
status.4,12,13Even without physical injury, CPR can lead to
psychological harm that lowers survivors’ quality of life.
Starting in the mid 1970s, hospitals began to implement
policies on DNR orders due to concerns that universal CPR
could cause more harm than benefit for some patients. These
policies served to establish procedures for writing DNR orders,
but differed widely across hospitals.14In 1983, The President's
Commission for the Study of Ethical Problems in Medicine
supported DNR order protocols based on three value consid-
erations: self-determination, well-being, and equity.15First,
the decision for a DNR order should be based foremost on a
competent patient’s preference or the previously stated ad-
vance directive of a patient who became incompetent. Second,
under the principle of well-being, the decision to withhold CPR
can be justified when the intervention will not benefit the
patient. The Commission acknowledged that the question of
“benefit” is a value-laden one. It involves weighing both the
physician’s medical assessment of the chance of success and
the patient’s values and goals of care in order to make an
adequate determination of benefit. Finally, the Commission
believes that resuscitation is a component of care to which all
patients should have equitable access and that decisions
should not be guided by the concern that the costs incurred
could overweigh the potential benefits for some patients.
Although intended to promote patient self-determination
and prevent non-beneficial interventions, DNR orders often fail
to do so. This is because the necessary discussions between
physicians and patients or surrogates are often inadequate or
absent. In 1991, the passage of the Patient Self-Determination
Act (PSDA) required all health care institutions to inform
patients about their right to complete an advance directive,
including their right to refuse life-sustaining interventions
such as CPR.16In the years following the PSDA, however,
patients were still not significantly involved in decisions
regarding resuscitation. The SUPPORT Investigators found
that among seriously ill hospitalized patients who wanted
CPR to be withheld, half did not have a written DNR order.17
Furthermore, the patterns of DNR orders suggested that physi-
Received August 9, 2010
Revised December 16, 2010
Accepted December 27, 2010
Published online February 1, 2011
cian- and institution-related biases had a stronger influence on
the timing and selection of patients for DNR orders than patient-
related factors such as the presence of advance directives.18,19
Although problems with DNR orders have been discussed for
decades, substantial efforts at reform proved inadequate.
Fortunately, the recent health care reform has created a
national impetus to promote safe, high quality care and
eliminate costly, ineffective treatments.20,21Now is the oppor-
tune time to tackle the problems with DNR orders and push for
quality DNR discussions that promote patient-centered care
and prevent harmful interventions. In this article, we describe
the persistent problems with hospital DNR orders in practice
today. We also provide reasons why physicians frequently fail to
conduct informed DNR discussions. Finally, we offer a set of
strategies to implement on the national, institutional, and
physician level that could help to improve conversations
regarding resuscitation decisions.
PROBLEMS WITH DNR ORDERS IN PRACTICE
Four ways in which DNR orders remain problematic today
preferences regarding resuscitation are neglected.
patients to participate in decisions regarding resuscitation.
patients to make informed decisions.
DNR discussions occur too infrequently and patients’
DNR discussions are delayed until it is too late for the
Physicians do not provide adequate information to allow
Physicians inappropriately extrapolate DNR orders to limit
DNR discussions: too little and too late. Among hospitalized
patients, patient-physician communication about preferences
for CPR is inadequate. Many seriously ill patients did not have
an opportunity to discuss resuscitation preferences with their
physicians, including half of those who wanted resuscitation to
be withheld.22,23Physicians were able to successfully predict
the resuscitation preferences of patients who wanted a DNR
order less than half the time.24,25Thus, many patients are at
risk of being resuscitated against their wishes.
When DNR order discussions do occur, they frequently
occur too late.26,27A study of 500 patients who suffered from
a cardiac arrest showed that 76% of these patients with DNR
orders were incapacitated to make decisions at the time a DNR
order was discussed.28However, only 11% were impaired at
the time of admission. Only 22% of patients participated in the
decision about their DNR order. The majority of DNR orders
were written within 2 to 3 days before death.29,30The burden
of decision-making was transferred to surrogates, often family
members.28This is problematic because family members are
frequently unfamiliar with the procedures involved in CPR,
lack accurate information about patients’ prognoses, and
routinely overestimate patients’ preferences for CPR and other
DNR discussions fail to satisfy criteria for informed
consent. DNR discussions often omit essential information to
allow patients or surrogates to make informed decisions.
Tulsky and colleagues’ analysis of tape-recorded DNR discus-
sions led by medical residents found that only 4% of residents
discussed the chances of survival after CPR, and only in vague,
qualitative terms.33Discussions about the risks of CPR were
rare. Only two residents mentioned natural death and comfort
care measures as alternatives to choosing a resuscitation
attempt. Providing education about the risks and success
rates of CPR is especially critical since the majority of the
general population have unrealistically high expectations of
successful recovery after CPR due, in part, to its inaccurate
portrayal in the mass media.34–36In one study, more than 80%
of respondents over the age of 70 believed that the survival rate
to hospital discharge after CPR was at least 50%.37Further-
more, residents often discuss CPR as a hypothetical standard
topic and focus on listing the procedures involved in a scripted,
depersonalized manner.38They neglect to elicit the patient’s
treatment values and goals, and fail to provide a recommen-
dation based on these goals. Patients or surrogates are thus
often left to make decisions that are poorly informed.
Health care professionals inappropriately extrapolate DNR
orders to other treatment decisions. A DNR order only
applies to the decision to withhold CPR in the event of a
cardiopulmonary arrest and should not impact other aspects
of care. However, many providers inappropriately alter treat-
ment plans for patients with a DNR order without discussion
with the patient or surrogate.39In one survey of 155 medicine
and surgery residents, 43% would withhold blood products
and 32% would not give antibiotics to a patient with a DNR
order.40Some believe that diagnostic tests should not be
ordered when a patient is “DNR.” This may be due to
misunderstanding the scope of DNR orders by some providers.
Still, other providers intentionally apply DNR orders broadly
because they either assume that patients with DNR orders
would also prefer to abstain from other life-sustaining treat-
ments or believe that other treatments would not be medically
beneficial.39They make assumptions to avoid a discussion
with patients about end-of-life preferences because of the lack
of time or discomfort with having the conversation.41While
these providers may believe their decisions are made in the
patient’s best interest, their judgment is subjected to personal
biases and their assumptions can be faulty.
REASONS FOR INADEQUATE DNR DISCUSSIONS
AND RECOMMENDED STRATEGIES FOR CHANGE
The problems with DNR orders described above are derived
from deficient physician behaviors. Past efforts to improve
implementation of DNR orders, such as revising DNR consent
forms, have had limited success because they failed to change
physician behavior.42One poignant example is the $29 million
SUPPORT intervention that aimed to improve communication
and shared end-of-life decision-making between seriously ill
patients and their physicians.24The results showed that
providing information on patients’ preferences and prognosis
to physicians, as well as access to trained nurses to facilitate
communication, did not improve physician-patient communi-
cation. The intervention neither improved the incidence or
timing of DNR orders nor physicians’ knowledge of patients’
preferences to withhold CPR.24
This intervention failed be-
Yuen et al.: Overcoming the problem of inadequate DNR discussions
cause it did not target systemic factors that affect physician
behavior.43Systems-based approaches have been found to be
instrumental in changing health care workers’ performance,
such as hand hygiene practices.44Likewise, tackling
entrenched institutional and professional practices surround-
ing DNR discussions requires a multifaceted approach that
creates incentives and tools to promote physician communi-
cation with patients and families. We identify four systemic
issues that contribute to deficient physician behaviors sur-
rounding DNR discussions and offer strategies to address each
(See Text Box 1).
Medical culture that values the technological imperative.
DNR order patterns reveal that physicians in procedure-oriented
specialties and institutions that offer cutting-edge medical care
are associated with lower rates of DNR orders. For example,
surgeons write fewer DNR orders and write them later in the
hospital course compared with internists.17,18,25Larger institu-
tions, academic centers, and hospitals in urban areas have lower
rates of DNR orders compared with smaller, nonacademic, and
rural hospitals.45While the lowerrates of DNR orders may reflect
the preferences of self-selected patients to a certain extent,
another likely contributing factor is the providers’ bias towards
proceeding with treatments rather than engaging in discussions
about goals of care and setting limits to further interventions.
Kaufman found that the decision for using life-extending
interventions such as implantable ICDs and dialysis in the
elderly population is largely driven by an institution’s practice
patterns, the technological imperative, and the growing normal-
ization of these treatments.46Providers may not be conscious
that they are imparting their views in framing options and
recommendations to patients. For example, in an analysis of
discussions about dialysis, physicians frame the subject as a
matter of “when you will need to start dialysis” and not “if.”
Patients at times were not aware that they could opt out of an
intervention. Changing the culture of practices at these institu-
tions is a necessary step towards more open communication
with patients about their prognosis, goals, and options.
Promoting high-quality end-of-life care that is patient-cen-
tered will bring about the culture change that leads to improved
communication about goals of care and code status decisions.
This was demonstrated by an intervention to integrate palliative
care into the multidisciplinary team of a trauma-surgical ICU at
a tertiary care medical center.47Upon patient admission to the
ICU, the provider determined the patient’s prognosis, prefer-
ences, and advance directives, and a family meeting was held
within 3 days to discuss outcomes, treatment options, and goals
of care. During bedside rounds, the focus was broadened to
encompass pain and symptom management as well as goals of
care. They found that implementation of DNR orders and
withdrawal of care decisions happened earlier. For deceased
patients, the total ICU length of stay was shortened. By setting
improving end-of-life care as a goal, the ICU team successfully
altered established practices by integrating enhanced commu-
nication between physicians, nurses, and families as a part of
the new ICU care bundle.
Already, a number of institutions have developed palliative
care improvement initiatives that resulted in improved commu-
nication between providers and patients.48,49Elements that
contribute to successful organizational change include strong
leadership support and sponsorship, development of a consis-
tent organizational model, networking and information sharing
among providers, engagement of the staff to collaborate in
teamwork to test initiatives, and availability of performance
data that feed back to organizational leaders to sustain
Inadequate hospital policies on DNR discussion standards.
The Joint Commission (JC) requirements on hospital DNR
policy do not currently provide specific guidelines for DNR
discussions. Their standards state that hospital DNR policies
ought to 1) provide mechanisms for reaching decisions and
resolving conflicts, 2) describe the role of physicians, other staff
and family members in the decision, as well as 3) require the
DNR order to be written by the attending physician.52There is
no requirement to ensure that a qualified provider leads the
DNR discussion and that the content of the discussion fulfills
criteria for informed consent.
While many states have enacted legislation on DNR orders,
the extent to which they explicitly set standards for DNR
discussions vary state by state. New York’s DNR law, the first
in the nation, stipulates that attending physicians be responsi-
ble for leading discussions that provide informed consent with
patients or surrogates.53However, the legislation does not
require hospitals to establish mechanisms to enforce the
integrity of the informed consent process and hold attending
Reasons for inadequate DNR discussions Proposed strategies
Medical culture that favors
Promote culture change to improve
patient-centered end-of-life care.
Inadequate hospital policies that do not
set standards for DNR discussions.
New Joint Commission standards for
Insufficient training of physicians to
discuss resuscitation preferences with
Establish formal communication skills
training programs in goals of care and
Payment system that rewards volume
and intensity of care.
Financial incentives that use patient
satisfaction and/or the quality of DNR
discussions as performance measures.
Text Box 1. Reasons for inadequate DNR discussions and strategies for addressing them
Yuen et al.: Overcoming the problem of inadequate DNR discussions
physicians accountable for leading discussions. They also do
not specify sanctions for noncompliant individuals. Not surpris-
ingly, the law failed to increase patient or family involvement in
informed decisions to withhold CPR,54,55and house officers
continued to be significantly involved in leading discussions.54
Due to the lack of clear regulatory requirements and
enforceable statutes, hospital policy on DNR protocols vary
widely across institutions and some hospital policies have been
shown to be confused about the scope of a DNR order.39In some
hospitals, it is mandatory to elicit the resuscitation preferences
of all patients who are admitted. Rather than viewing discus-
sions about DNR orders as an opportunity to open dialogue with
patients about their goals of treatment, many physicians feel
forced to discuss code status by institutional policy or fear of
malpractice lawsuits.56,57In teaching hospitals, this task is
often relegated to house officers or medical students, those who
are lowest in the medical hierarchy and are least experienced
with DNR discussions.56,58
We advocate for the Joint Commission (JC) to set specific
standards for DNR discussions and require institutions to
demonstrate compliance with these standards to be accredited.
The JC can bring about rapid changes to hospital practices
across the nation and ensure compliance by conducting
periodic institution site visits. The Commission’s positive impact
on hospitals’ pain assessment and management practices when
new guidelines were instituted in 2001 is illustrative. Health
care institutions responded quickly by implementing policies
and practices to adhere to the standards.59Many institutions
went beyond the requirements to create new pain management
programs that provide novel multidisciplinary approaches to
pain control.60Within 4 years of adoption, improved patient
satisfaction with pain control across 240 hospitals was demon-
The DNR discussion standards that we propose for adoption
by the JC are shown in Text Box 2. These standards include
identifying appropriate patients for DNR discussions, designat-
ing the attending physician to lead the discussions, defining the
timing for the discussions, ensuring that the decision-maker is
provided adequate information to make an informed decision,
and documenting the content of discussions and rationale for
the patient’s decision. Hospitals should be required to establish
mechanisms to enforce adherence, such as conducting chart
reviews of documented discussions. Electronic medical records
(EMRs) can increase the ease to document and monitor
compliance. For example, a mandatory field in EMRs could
prompt physicians to document within a set timeframe whether
or not the DNR discussion has occurred and require inclusion of
the discussion’s content or the reason for deferring the discus-
sion. Lastly, hospitals should develop mandatory educational
programs to teach the scope of DNR orders and train physicians
to lead proper DNR discussions.
Insufficient training of physicians in communication skills.
Accrediting bodies for medical schools and residency programs
do not require formal training in communication and decision-
making about DNR orders.62,63By default, most house officers
learn to lead DNR discussions informally through a “see one, do
one, teach one” approach whereby misconceptions about DNR
orders and inappropriate approaches can be perpetuated.64,65
Physicians-in-training often cite the paucity of role models as a
reason for their lack of competence in conducting DNR discus-
sions.33,66,67Unfortunately, the hidden curriculum in medical
education devalues end-of-life communication and conveys a
sense that caring for the dying is dissatisfying or uninterest-
ing.68,69However, as the health care reform movement engen-
ders growing interest in improving the quality of end-of-life care
nationally, there will be increasing demands on educators to
teach end-of-life issues and communication with patients about
goals of care and preferences regarding resuscitation. The
revolution and new advocates in the field of palliative care can
provide leadership in communication about and goal setting for
1. Attending physicians are responsible for leading informed DNR discussions with
appropriate patients or their surrogates.
2. Appropriate patients are defined as follows: 1) Patients with a terminal illness, 2) Patients
with poor functional status due to an illness or disabling condition that is severe and
irreversible (e.g., Class IV congestive heart failure, advanced COPD, advanced dementia,
3) Patients who suffered an irreversible loss of consciousness, 4) Patients with a low
likelihood of surviving resuscitation, 5) Patients who are at increased risk for cardiac or
and the Care of the Dying, 1987.
3. Process should include: 1) Determining the patient’s goals of care 2) Educating the
decision-maker of the patient’s disease course, prognosis, potential benefits and burdens
of CPR and alternative to CPR 3) Providing a recommendation (unless the patient or
surrogate objects) for or against resuscitation based on a medical assessment of the
likelihood that CPR will succeed and its benefits or lack thereof to the patient given the
4. Discussions should be conducted within 72 hours of hospitalization and revisited when
the patient’s clinical condition changes.
5. The content of discussion and rationale for the decision regarding resuscitation should be
documented in the patient’s medical record and the practitioners and staff involved in the
patient’s care should be made aware of the decision.
Adapted and modified from The Hastings Center’s Guidelines on the Termination of Life-Sustaining Treatment
Text Box 2. Proposed Joint Commission standards for DNR discussions
Yuen et al.: Overcoming the problem of inadequate DNR discussions
An important distinction between DNR discussions and other
informed consent conversations about therapeutic treatments is
that the former is the only discussion to withhold a potentially
unwanted or non-beneficial intervention. Therefore, physicians
should be taught to identify appropriate patients with whom to
have the conversation, such as those with a serious illness for
whom CPR may not prolong survival or serve the patients’ goals.
They should also learn to frame the discussion by conveying the
goal of avoiding harm and provide a recommendation that is
values and goals and the probability of successful resuscitation.
There are studies demonstrating that these communication
skills can be taught and result in improved competence. Effective
strategies to teach communication skills in goals of care and
DNR discussions involve experiential learning. These include
direct observation and feedback of residents by palliative care
clinicians during real-life code status discussions,70using of
audio-visual triggers and role plays,71,72and standardized
patient exercises.73,74Additionally, teaching skills in breaking
bad news and managing family conflicts are also important to
prepare future providers to assist patients and families navigate
through the complex and difficult decisions surrounding resus-
Payment system that rewards volume and intensity of care.
The existing “fee-for-service” reimbursement system in the
United States leads to overtreatment of those with serious, life-
limiting conditions and often does not improve patient outcomes.
Under this payment model, it is not surprising that for-profit
hospitals that are associated with more costly and greater
intensity of care also have lower rates of early DNR orders.45To
change institutional practices to increase the incidence and
improve the timeliness of code status discussions, the incentives
system will need to be better aligned to motivate hospitals and
providers to provide care that is patient-centered.
Pay for performance initiatives have shown that establishing
quality measures for care practices coupled with rewards have
changed physician practices and improved outcomes.75In the
ambulatory care setting, financial incentives that promote
patient care experiences measured by patient satisfaction
(CAHPS) survey data have led to meaningful improvement in
physician-patient communication.76Currently, the Veterans
Affairs (VA) system is using family satisfaction surveys to identify
performance measures of quality end-of-life care.77They found
that families of patients who received a palliative care consulta-
tion and of patients who had a DNR order before death reported
substantially higher satisfaction with care. These findings sug-
gest that timely and informed DNR discussions with seriously ill
patients or their families contribute to higher quality of care.
Rewarding hospitals that promote care that is patient-
centered and respects patient preferences at the end-of-life will
in turn exert pressure on providers to conduct more goals of
care and DNR discussions. The quality of DNR discussions can
be used as a performance measure of patient-centered care,
such as by scoring their timeliness to allow patients to
participate in the decision-making, whether or not the patient’s
values and goals of care were determined, and whether the
decision reached was consistent with the patient’s goals.
Hospitals can motivate physicians via nonfinancial means such
as through public reporting of patient satisfaction with provider
communication and recognition awards for physicians who
demonstrate exemplary patient-centered care.
The notion of providing payment for conversations with
patients and families about preferences for end-of-life treat-
ments may encounter resistance from those who opposed the
proposed advance care planning legislation in the recent health
care reform. The opponents accused the bill as the government’s
ploy to ration health care for the elderly, using the catchphrase
“death panels” to incite fear among the public.78In doing so, the
legislation was reframed not in the terms of promoting patient
choice as it was intended, but in taking away choice. In reality,
conversations about patients’ goals and preferences for resusci-
tation are meant to promote patient autonomy and to achieve
outcomes that are consistent with patients’ preferences. The
National Priorities Partnership has identified achieving patient-
centered care and improving end-of-life care as two of the six
national priorities that have the potential to rapidly and
substantially improve health care quality.20To be effective, the
resulting debates and policies must be framed to encourage
conversations that inform patients and families about the
potential for life-sustaining treatments to do both good and
harm to patients at the end of life.
Fifteen yearshave passedsince the SUPPORT trial, the last large-
scale effort to improve communication between physicians and
patients about end-of-life decisions. Since that time, there has
been increasing focus on promoting quality of care for the dying,
as exemplified by the improvement in pain management and
explosion of hospital-based palliative care programs across the
country.79However, the persistent problems with DNR orders
suggest that physician behaviors toward communication with
patients about goals of care and resuscitation decisions have not
measurably changed in the past 20 years. Given the pressures
brought on by the health care reform to improve the quality of
care and to eliminate ineffective care, it is timely toreexamine the
underlying reasons that hinder physician behavior change. We
believe that our health care infrastructure today is primed to
overcome the current challenges. Such changes are imperative
for enhancing communication with patients and families about
their goals and involving them in informed decisions about
Funding Sources: Dr. Fetters’ participation in this work was made
possible in part through the generous support of the Jitsukoukai
Foundation. Dr. Reid is supported by grants from the John A.
Hartford foundation (Center of Excellence in Geriatric Medicine
Award) and the National Institute on Aging (P30 AG22845-07).
Conflict of Interest: None disclosed.
Prior Presentations: None.
Corresponding Author: M. Carrington Reid, MD, PhD; Division of
Geriatrics and Gerontology, Weill Medical College, Cornell University,
525 E 68th Street, Box 39, New York, NY 10065, USA
1. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac
massage. JAMA. 1960;173:1064–7.
Yuen et al.: Overcoming the problem of inadequate DNR discussions
2. Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after
cardiopulmonary resuscitation in the hospital. N Engl J Med.
3. Schiedermayer DL. The decision to forgo CPR in the elderly patient.
4. Moss AH. Informing the patient about cardiopulmonary resuscitation:
when the risks outweigh the benefits. J Gen Intern Med. 1989;4:349–55.
5. Saklayen M, Liss H, Markert R. In-hospital cardiopulmonary resusci-
tation. Survival in 1 hospital and literature review. Medicine (Baltimore).
6. Schultz SC, Cullinane DC, Pasquale MD, Magnant C, Evans SR.
Predicting in-hospital mortality during cardiopulmonary resuscitation.
7. Khalafi K, Ravakhah K, West BC. Avoiding the futility of resuscitation.
8. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-
hospital cardiopulmonary resuscitation in the elderly. N Engl J Med.
9. Tian J, Kaufman DA, Zarich S, et al. Outcomes of critically ill patients
who received cardiopulmonary resuscitation. Am J Respir Crit Care Med.
10. Faber-Langendoen K. Resuscitation of patients with metastatic cancer.
Is transient benefit still futile? Arch Intern Med. 1991;151:235–9.
11. Reisfield GM, Wallace SK, Munsell MF, Webb FJ, Alvarez ER, Wilson
GR. Survival in cancer patients undergoing in-hospital cardiopulmonary
resuscitation: A meta-analysis. Resuscitation. 2006;71:152–60.
12. Jaffe AS, Landau WM. Death after death: The presumption of informed
consent for cardiopulmonary resuscitation—ethical paradox and clinical
conundrum. Neurology. 1993;43:2173–8.
13. Ebell MH. Prearrest predictors of survival following in-hospital cardio-
pulmonary resuscitation: A meta-analysis. J Fam Pract. 1992;34:551–8.
14. Baker R. Beyond do-not-resuscitate orders. In: Strosberg MA, Fein IA,
Carroll JD, ed. Rationing of Medical Care for the Critically Ill. Washing-
ton, DC: Brookings Institute Press, 1989.
15. President's Commission for the Study of Ethical Problems in Medicine
and Biomedical and Behavioral Research. Deciding to Forego Life-
Sustaining Treatment. Washington, DC: Government Printing Office,
16. Omnibus Budget Reconciliation Act of 1990 (OBRA-90). Public law no.
17. Hakim RB, Teno JM, Harrell FE Jr, et al. Factors associated with do-
not-resuscitate orders: Patients' preferences, prognoses, and physicians'
judgments. SUPPORT Investigators. Study to Understand Prognoses and
Preferences for Outcomes and Risks of Treatment. Ann Intern Med.
18. Morrell ED, Brown BP, Qi R, Drabiak K, Helft PR. The do-not-
resuscitate order: Associations with advance directives, physician spe-
cialty and documentation of discussion 15 years after the Patient Self-
Determination Act. J Med Ethics. 2008;34:642–7.
19. Burns JP, Edwards J, Johnson J, Cassem NH, Truog RD. Do-not-
resuscitate order after 25 years. Crit Care Med. 2003;31:1543–50.
20. The National Priorities Partnership. A Vision for World-Class, Affordable
Healthcare. Available at: http://www.nationalprioritiespartnership.org/
Priorities.aspx. Accessed December 13, 2010.
21. O'Kane ME. Performance-based measures: The early results are in. J
Manag Care Pharm. 2007;13:S3–6.
22. Hofmann JC, Wenger NS, Davis RB, et al. Patient preferences for
communication with physicians about end-of-life decisions. SUPPORT
Investigators. Study to Understand Prognoses and Preference for Out-
comes and Risks of Treatment. Ann Intern Med. 1997;127:1–12.
23. Golin CE, Wenger NS, Liu H, et al. A prospective study of patient-
physician communication about resuscitation. J Am Geriatr Soc.
24. A controlled trial to improve care for seriously ill hospitalized patients.
The study to understand prognoses and preferences for outcomes and
risks of treatments (SUPPORT). The SUPPORT Principal Investigators.
25. Covinsky KE, Fuller JD, Yaffe K, et al. Communication and decision-
making in seriously ill patients: Findings of the SUPPORT Project. The
Study to Understand Prognoses and Preferences for Outcomes and Risks
of Treatments. J Am Geriatr Soc. 2000;48:S187–93.
26. Weiss GL, Hite CA. The do-not-resuscitate decision: The context,
process, and consequences of DNR orders. Death Stud. 2000;24:307–23.
27. Layson RT, Adelman HM, Wallach PM, Pfeifer MP, Johnston S,
McNutt RA. Discussions about the use of life-sustaining treatments: A
literature review of physicians' and patients' attitudes and practices. End
of Life Study Group. J Clin Ethics. 1994;5:195–203.
28. Bedell SE, Pelle D, Maher PL, Cleary PD. Do-not-resuscitate orders for
critically ill patients in the hospital. How are they used and what is their
impact? JAMA. 1986;256:233–7.
29. Baker DW, Einstadter D, Husak S, Cebul RD. Changes in the use of do-
not-resuscitate orders after implementation of the Patient Self-Determi-
nation Act. J Gen Intern Med. 2003;18:343–9.
30. Maksoud A, Jahnigen DW, Skibinski CI. Do not resuscitate orders and
the cost of death. Arch Intern Med. 1993;153:1249–53.
31. Ditto PH, Danks JH, Smucker WD, et al. Advance directives as acts of
communication: A randomized controlled trial. Arch Intern Med.
32. Cherniack EP. Increasing use of DNR orders in the elderly worldwide:
Whose choice is it? J Med Ethics. 2002;28:303–7.
33. Tulsky JA, Chesney MA, Lo B. How do medical residents discuss
resuscitation with patients? J Gen Intern Med. 1995;10:436–42.
34. Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life
care: Perceptions of seriously ill patients and their family members.
35. Jones GK, Brewer KL, Garrison HG. Public expectations of survival
following cardiopulmonary resuscitation. Acad Emerg Med. 2000;7:48–
36. Godkin MD, Toth EL. Cardiopulmonary resuscitation and older adults'
expectations. Gerontologist. 1994;34:797–802.
37. Adams DH, Snedden DP. How misconceptions among elderly patients
regarding survival outcomes of inpatient cardiopulmonary resuscitation
affect do-not-resuscitate orders. J Am Osteopath Assoc. 2006;106:402–4.
38. Deep KS, Griffith CH, Wilson JF. Communicationdecision making
about life-sustaining treatment: Examining the experiences of resident
physicians and seriously-ill hospitalized patients. J Gen Intern Med.
39. Beach MC, Morrison RS. The effect of do-not-resuscitate orders on
physician decision-making. J Am Geriatr Soc. 2002;50:2057–61.
40. Gorman TE, Ahern SP, Wiseman J, Skrobik Y. Residents' end-of-life
decision making with adult hospitalized patients: A review of the
literature. Acad Med. 2005;80:622–33.
41. Calam B, Far S, Andrew R. Discussions of "code status" on a family
practice teaching ward: what barriers do family physicians face? CMAJ.
42. Sulmasy DP, Sood JR, Texiera K, McAuley RL, McGugins J, Ury WA. A
prospective trial of a new policy eliminating signed consent for do not
resuscitate orders. J Gen Intern Med 2006.
43. Lynn J, De Vries KO, Arkes HR, et al. Ineffectiveness of the SUPPORT
Intervention: Review of explanations. J Am Geriatr Soc. 2000;48:S206–13.
44. Lederer JW Jr, Best D, Hendrix V. A comprehensive hand hygiene
approach to reducing MRSA health care-associated infections. Jt Comm
J Qual Patient Saf. 2009;35:180–5.
45. Zingmond DS, Wenger NS. Regional and institutional variation in the
initiation of early do-not-resuscitate orders. Arch Intern Med.
46. Kaufman SR, Shim JK, Russ AJ. Old age, life extension, and the
character of medical choice. J Gerontol B Psychol Sci Soc Sci. 2006;61:
47. Mosenthal AC, Murphy PA, Barker LK, Lavery R, Retano A, Living-
ston DH. Changing the culture around end-of-life care in the trauma
intensive care unit. J Trauma. 2008;64:1587–93.
48. Lynn J, Schall MW, Milne C, Nolan KM, Kabcenell A. Quality
improvements in end of life care: Insights from two collaboratives. Jt
Comm J Qual Improv. 2000;26:254–67.
49. Gould DA, Lynn J, Halper D, Myers SK, Simon L, Holmes H. The New
York City Palliative Care Quality Improvement Collaborative. Jt Comm J
Qual Patient Saf. 2007;33:307–16.
50. Lukas CV, Holmes SK, Cohen AB, et al. Transformational change in
health care systems: an organizational model. Health Care Manage Rev.
51. Ferris FD, Librach SL. Models, standards, guidelines. Clin Geriatr Med.
52. The Joint Commission. 1994 Accreditation Manual for Hospitals. Volume
I: Standards. Illinois: Oakbrook Terrace, 1994.
53. Thuillez, Ford, Gold, Butler & Young LLP. New York Health Law: A
Guide for Health Care Providers. Albany: New York, 2008.
54. Kamer RS, Dieck EM, McClung JA, White PA, Sivak SL. Effect of New
York State's do-not-resuscitate legislation on in-hospital cardiopulmo-
nary resuscitation practice. Am J Med. 1990;88:108–11.
Yuen et al.: Overcoming the problem of inadequate DNR discussions
55. Quill TE, Bennett NM. The effects of a hospital policy and state
legislation on resuscitation orders for geriatric patients. Arch Intern
56. Weissman DE. Do not resuscitate orders: a call for reform. J Palliat Med.
57. Goetzler RM, Moskowitz MA. Changes in physician attitudes toward
limiting care of critically ill patients. Arch Intern Med. 1991;151:1537–40.
58. Smedira NG, Evans BH, Grais LS, et al. Withholding and withdrawal of
life support from the critically ill. N Engl J Med. 1990;322:309–15.
59. Gordon DB, Rees SM, McCausland MR, et al. Improving reassessment
and documentation of pain management. Jt Comm J Qual Patient Saf.
60. Haugh R. Hospitals and clinicians confront a new imperative: pain
management. Hosp Health Netw 2005;79:51,2, 54-6, 2.
61. Leddy KM, Wolosin RJ. Patient satisfaction with pain control during
hospitalization. Jt Comm J Qual Patient Saf. 2005;31:507–13.
62. Liaison Committee on Medical Education (LCME). Accreditation Stan-
dards. Available at: http://www.lcme.org/standard.htm. Accessed De-
cember 13, 2010.
63. The Accreditation Council for Graduate Medical Education (ACGME).
Available at: http://www.acgme.org/acWebsite/home/home.asp.
Accessed December 13, 2010.
64. Tulsky JA, Chesney MA, Lo B. See one, do one, teach one? House staff
experience discussing do-not-resuscitate orders. Arch Intern Med.
65. Deep KS, Green SF, Griffith CH, Wilson JF. Medical residents'
perspectives on discussions of advanced directives: can prior experience
affect how they approach patients? J Palliat Med. 2007;10:712–20.
66. La Puma J, Silverstein MD, Stocking CB, Roland D, Siegler M. Life-
sustaining treatment. A prospective study of patients with DNR orders in
a teaching hospital. Arch Intern Med. 1988;148:2193–8.
67. Buss MK, Alexander GC, Switzer GE, Arnold RM. Assessing competence of
residents to discuss end-of-life issues. J Palliat Med. 2005;8:363–71.
68. Sullivan AM, Lakoma MD, Block SD. The status of medical
education in end-of-life care: a national report. J Gen Intern Med.
69. Arnold RM. Formal, informal, and hidden curriculum in the clinical
years: where is the problem? J Palliat Med. 2007;10:646–8.
70. Han PK, Keranen LB, Lescisin DA, Arnold RM. The palliative care
clinical evaluation exercise (CEX): an experience-based intervention
for teaching end-of-life communication skills. Acad Med.
71. Alexander SC, Keitz SA, Sloane R, Tulsky JA. A controlled trial of a
short course to improve residents' communication with patients at the
end of life. Acad Med. 2006;81:1008–12.
72. McFarland KF, Rhoades DR. End-of-life care: a retreat format for
residents. J Palliat Med. 2006;9:82–9.
73. Lorin S, Rho L, Wisnivesky JP, Nierman DM. Improving medical
student intensive care unit communication skills: a novel educational
initiative using standardized family members. Crit Care Med.
74. Hales BM, Hawryluck L. An interactive educational workshop to
improve end of life communication skills. J Contin Educ Health Prof.
2008;28:241–8. quiz 249-55.
75. O'Kane M, Corrigan J, Foote SM, et al. Crossroads in quality. Health
Aff (Millwood). 2008;27:749–58.
76. Rodriguez HP, von Glahn T, Elliott MN, Rogers WH, Safran DG. The
effect of performance-based financial incentives on improving patient
care experiences: a statewide evaluation. J Gen Intern Med.
77. Finlay E, Shreve S, Casarett D. Nationwide veterans affairs quality
measure for cancer: the family assessment of treatment at end of life. J
Clin Oncol. 2008;26:3838–44.
78. Fried TR, Drickamer M. Garnering support for advance care planning.
79. Meier DE. Palliative care in hospitals. J Hosp Med. 2006;1:21–8.
Yuen et al.: Overcoming the problem of inadequate DNR discussions