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Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

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Abstract

BACKGROUND

The majority of patients who die in hospital have a “Do Not Resuscitate” (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don’t, and how they view discussions of resuscitation status.

METHODS

We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach.

RESULTS

We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant’s preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.

CONCLUSION

Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

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Conflict of Interest

None disclosed.

Funding Source

Associated Medical Services, Incorporated provided financial assistance in the form of a fellowship grant to three of the authors (JD, JM, and HB). This money was used to pay for recording equipment and professional transcription services.

Statement of Submitting Author

JD has had full access to all the data in the study and had final responsibility for the decision to submit it for publication.

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Authors and Affiliations

  1. Department of Medicine, University of Toronto, 200 Elizabeth St. 9N-926, Toronto, M5G 2C4, Canada

    James Downar MDCM, MHSc, FRCP(C), Tracy Luk MD, FRCP(C), Hershl Berman MD, FRCP(C) & Laura Hawryluck MD, MSc, FRCP(C)

  2. Department of Ethics, London Health Sciences Centre, London, Canada

    Robert W. Sibbald MSc

  3. Research Ethics Board, Mount Sinai Hospital, Toronto, Canada

    Tatiana Santini BHSc, RRT

  4. Division of Hematology-Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA

    Joseph Mikhael MD, MEd, FRCP(C)

Authors
  1. James Downar MDCM, MHSc, FRCP(C)
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  2. Tracy Luk MD, FRCP(C)
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  3. Robert W. Sibbald MSc
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  4. Tatiana Santini BHSc, RRT
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  5. Joseph Mikhael MD, MEd, FRCP(C)
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  6. Hershl Berman MD, FRCP(C)
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  7. Laura Hawryluck MD, MSc, FRCP(C)
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Corresponding author

Correspondence to James Downar MDCM, MHSc, FRCP(C).

Additional information

JD, RWS, JM, and LH all contributed to study design. JD and TL conducted literature searches. JD, TL, and RWS conducted the interviews and analyzed the data. All authors participated in data interpretation. JD wrote the original manuscript, and all authors participated in critical revision.

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Downar, J., Luk, T., Sibbald, R.W. et al. Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients. J GEN INTERN MED 26, 582–587 (2011). https://doi.org/10.1007/s11606-010-1616-2

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  • DOI: https://doi.org/10.1007/s11606-010-1616-2

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