Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them


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.

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  1. 1.

    Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064–7.

    PubMed  CAS  Google Scholar 

  2. 2.

    Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med. 1983;309:569–76.

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Schiedermayer DL. The decision to forgo CPR in the elderly patient. JAMA. 1988;260:2096–7.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Moss AH. Informing the patient about cardiopulmonary resuscitation: when the risks outweigh the benefits. J Gen Intern Med. 1989;4:349–55.

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Saklayen M, Liss H, Markert R. In-hospital cardiopulmonary resuscitation. Survival in 1 hospital and literature review. Medicine (Baltimore). 1995;74:163–75.

    Article  CAS  Google Scholar 

  6. 6.

    Schultz SC, Cullinane DC, Pasquale MD, Magnant C, Evans SR. Predicting in-hospital mortality during cardiopulmonary resuscitation. Resuscitation. 1996;33:13–7.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Khalafi K, Ravakhah K, West BC. Avoiding the futility of resuscitation. Resuscitation. 2001;50:161–6.

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361:22–31.

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Tian J, Kaufman DA, Zarich S, et al. Outcomes of critically ill patients who received cardiopulmonary resuscitation. Am J Respir Crit Care Med. 2010;182:501–6.

    PubMed  Article  Google Scholar 

  10. 10.

    Faber-Langendoen K. Resuscitation of patients with metastatic cancer. Is transient benefit still futile? Arch Intern Med. 1991;151:235–9.

    PubMed  Article  CAS  Google Scholar 

  11. 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.

    PubMed  Article  Google Scholar 

  12. 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.

    PubMed  CAS  Google Scholar 

  13. 13.

    Ebell MH. Prearrest predictors of survival following in-hospital cardiopulmonary resuscitation: A meta-analysis. J Fam Pract. 1992;34:551–8.

    PubMed  CAS  Google Scholar 

  14. 14.

    Baker R. Beyond do-not-resuscitate orders. In: Strosberg MA, Fein IA, Carroll JD, ed. Rationing of Medical Care for the Critically Ill. Washington, DC: Brookings Institute Press, 1989.

  15. 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, 1983.

  16. 16.

    Omnibus Budget Reconciliation Act of 1990 (OBRA-90). Public law no. 101-508. 2002

  17. 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. 1996;125:284–93.

    PubMed  CAS  Google Scholar 

  18. 18.

    Morrell ED, Brown BP, Qi R, Drabiak K, Helft PR. The do-not-resuscitate order: Associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act. J Med Ethics. 2008;34:642–7.

    PubMed  Article  CAS  Google Scholar 

  19. 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.

    PubMed  Article  Google Scholar 

  20. 20.

    The National Priorities Partnership. A Vision for World-Class, Affordable Healthcare. Available at: Accessed December 13, 2010.

  21. 21.

    O'Kane ME. Performance-based measures: The early results are in. J Manag Care Pharm. 2007;13:S3–6.

    PubMed  Google Scholar 

  22. 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 Outcomes and Risks of Treatment. Ann Intern Med. 1997;127:1–12.

    PubMed  CAS  Google Scholar 

  23. 23.

    Golin CE, Wenger NS, Liu H, et al. A prospective study of patient-physician communication about resuscitation. J Am Geriatr Soc. 2000;48:S52–60.

    PubMed  CAS  Google Scholar 

  24. 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. JAMA 1995;274:1591-8.

  25. 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.

    PubMed  CAS  Google Scholar 

  26. 26.

    Weiss GL, Hite CA. The do-not-resuscitate decision: The context, process, and consequences of DNR orders. Death Stud. 2000;24:307–23.

    PubMed  Article  CAS  Google Scholar 

  27. 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.

    PubMed  CAS  Google Scholar 

  28. 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.

    PubMed  Article  CAS  Google Scholar 

  29. 29.

    Baker DW, Einstadter D, Husak S, Cebul RD. Changes in the use of do-not-resuscitate orders after implementation of the Patient Self-Determination Act. J Gen Intern Med. 2003;18:343–9.

    PubMed  Article  Google Scholar 

  30. 30.

    Maksoud A, Jahnigen DW, Skibinski CI. Do not resuscitate orders and the cost of death. Arch Intern Med. 1993;153:1249–53.

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Ditto PH, Danks JH, Smucker WD, et al. Advance directives as acts of communication: A randomized controlled trial. Arch Intern Med. 2001;161:421–30.

    PubMed  Article  CAS  Google Scholar 

  32. 32.

    Cherniack EP. Increasing use of DNR orders in the elderly worldwide: Whose choice is it? J Med Ethics. 2002;28:303–7.

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Tulsky JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients? J Gen Intern Med. 1995;10:436–42.

    PubMed  Article  CAS  Google Scholar 

  34. 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. CMAJ. 2006;174:627–33.

    PubMed  Google Scholar 

  35. 35.

    Jones GK, Brewer KL, Garrison HG. Public expectations of survival following cardiopulmonary resuscitation. Acad Emerg Med. 2000;7:48–53.

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    Godkin MD, Toth EL. Cardiopulmonary resuscitation and older adults' expectations. Gerontologist. 1994;34:797–802.

    PubMed  CAS  Google Scholar 

  37. 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.

    PubMed  Google Scholar 

  38. 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. 2008;23:1877–82.

    PubMed  Article  Google Scholar 

  39. 39.

    Beach MC, Morrison RS. The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc. 2002;50:2057–61.

    PubMed  Article  Google Scholar 

  40. 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.

    PubMed  Article  Google Scholar 

  41. 41.

    Calam B, Far S, Andrew R. Discussions of "code status" on a family practice teaching ward: what barriers do family physicians face? CMAJ. 2000;163:1255–9.

    PubMed  CAS  Google Scholar 

  42. 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. 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.

    PubMed  CAS  Google Scholar 

  44. 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.

    PubMed  Google Scholar 

  45. 45.

    Zingmond DS, Wenger NS. Regional and institutional variation in the initiation of early do-not-resuscitate orders. Arch Intern Med. 2005;165:1705–12.

    PubMed  Article  Google Scholar 

  46. 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:S175–84.

    PubMed  Google Scholar 

  47. 47.

    Mosenthal AC, Murphy PA, Barker LK, Lavery R, Retano A, Livingston DH. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;64:1587–93.

    PubMed  Article  Google Scholar 

  48. 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.

    PubMed  CAS  Google Scholar 

  49. 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.

    PubMed  Google Scholar 

  50. 50.

    Lukas CV, Holmes SK, Cohen AB, et al. Transformational change in health care systems: an organizational model. Health Care Manage Rev. 2007;32:309–20.

    PubMed  Google Scholar 

  51. 51.

    Ferris FD, Librach SL. Models, standards, guidelines. Clin Geriatr Med. 2005;21:17–44.

    PubMed  Article  Google Scholar 

  52. 52.

    The Joint Commission. 1994 Accreditation Manual for Hospitals. Volume I: Standards. Illinois: Oakbrook Terrace, 1994.

  53. 53.

    Thuillez, Ford, Gold, Butler & Young LLP. New York Health Law: A Guide for Health Care Providers. Albany: New York, 2008.

  54. 54.

    Kamer RS, Dieck EM, McClung JA, White PA, Sivak SL. Effect of New York State's do-not-resuscitate legislation on in-hospital cardiopulmonary resuscitation practice. Am J Med. 1990;88:108–11.

    PubMed  Article  CAS  Google Scholar 

  55. 55.

    Quill TE, Bennett NM. The effects of a hospital policy and state legislation on resuscitation orders for geriatric patients. Arch Intern Med. 1992;152:569–72.

    PubMed  Article  CAS  Google Scholar 

  56. 56.

    Weissman DE. Do not resuscitate orders: a call for reform. J Palliat Med. 1999;2:149–52.

    PubMed  Article  CAS  Google Scholar 

  57. 57.

    Goetzler RM, Moskowitz MA. Changes in physician attitudes toward limiting care of critically ill patients. Arch Intern Med. 1991;151:1537–40.

    PubMed  Article  CAS  Google Scholar 

  58. 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.

    PubMed  Article  CAS  Google Scholar 

  59. 59.

    Gordon DB, Rees SM, McCausland MR, et al. Improving reassessment and documentation of pain management. Jt Comm J Qual Patient Saf. 2008;34:509–17.

    PubMed  Google Scholar 

  60. 60.

    Haugh R. Hospitals and clinicians confront a new imperative: pain management. Hosp Health Netw 2005;79:51,2, 54-6, 2.

    Google Scholar 

  61. 61.

    Leddy KM, Wolosin RJ. Patient satisfaction with pain control during hospitalization. Jt Comm J Qual Patient Saf. 2005;31:507–13.

    PubMed  Google Scholar 

  62. 62.

    Liaison Committee on Medical Education (LCME). Accreditation Standards. Available at: Accessed December 13, 2010.

  63. 63.

    The Accreditation Council for Graduate Medical Education (ACGME). Available at: Accessed December 13, 2010.

  64. 64.

    Tulsky JA, Chesney MA, Lo B. See one, do one, teach one? House staff experience discussing do-not-resuscitate orders. Arch Intern Med. 1996;156:1285–9.

    PubMed  Article  CAS  Google Scholar 

  65. 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.

    PubMed  Article  Google Scholar 

  66. 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.

    PubMed  Article  Google Scholar 

  67. 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.

    PubMed  Article  Google Scholar 

  68. 68.

    Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685–95.

    PubMed  Article  Google Scholar 

  69. 69.

    Arnold RM. Formal, informal, and hidden curriculum in the clinical years: where is the problem? J Palliat Med. 2007;10:646–8.

    PubMed  Article  Google Scholar 

  70. 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. 2005;80:669–76.

    PubMed  Article  Google Scholar 

  71. 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.

    PubMed  Article  Google Scholar 

  72. 72.

    McFarland KF, Rhoades DR. End-of-life care: a retreat format for residents. J Palliat Med. 2006;9:82–9.

    PubMed  Article  Google Scholar 

  73. 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. 2006;34:2386–91.

    PubMed  Article  Google Scholar 

  74. 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.

    PubMed  Article  Google Scholar 

  75. 75.

    O'Kane M, Corrigan J, Foote SM, et al. Crossroads in quality. Health Aff (Millwood). 2008;27:749–58.

    Article  Google Scholar 

  76. 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. 2009;24:1281–8.

    PubMed  Article  Google Scholar 

  77. 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.

    PubMed  Article  Google Scholar 

  78. 78.

    Fried TR, Drickamer M. Garnering support for advance care planning. JAMA. 2010;303:269–70.

    PubMed  Article  CAS  Google Scholar 

  79. 79.

    Meier DE. Palliative care in hospitals. J Hosp Med. 2006;1:21–8.

    PubMed  Article  Google Scholar 

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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).

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None disclosed.

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Correspondence to M. Carrington Reid MD, PhD.

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Yuen, J.K., Reid, M.C. & Fetters, M.D. Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them. J GEN INTERN MED 26, 791–797 (2011).

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  • do-not-resuscitate orders
  • informed consent
  • end-of-life care