End of life discussion is very important for preventing undesired cardiopulmonary resuscitation (CPR). It is reportedly associated with less aggressive medical care near death and better quality of life. Its importance has been gradually recognized worldwide. However, the compliance of a Do-not-Resuscitate (DNR) order has not been well studied. We reported the incidence rate and the cause of non-compliance of DNR orders.
Patients were included if they had CPR in the adult care units in our hospital between April 1st, 2015 and September 30th, 2016. Patients’ code status at the time of and after the event of CPR were collected by retrospective chart review. We evaluated the cause of non-compliance of DNR orders if they received CPR despite the presence of DNR orders.
A total of 12795 patients over 18 years old were admitted to our hospital. CPR was performed for 59 patients (0.46%). Among these, 5 patients (8.4%) received CPR despite the presence of DNR orders. In 2 of the 5 cases, physicians initiated CPR without the check of code status because nobody around them was not sure of the code status. One case was that patient had VF rhythm during the ready for percutaneous cardiopulmonary support for emergent arterial valve replacement. The patient was recovered once and repeated code discussion reconfirmed his DNR order. He died soon after that. In the remaining 2 cases, code status was changed to full code after the recovery of spontaneous circulation (ROSC). One case was that 89-year old woman with acute heart failure had pulseless ventricular tachycardia. The physician who happened to pass by her thought CPR might be worth performing at least once and tried with successful ROSC. The repeated discussion with her family changed her code status into full code. She was discharged later with good neurological function. The other case was that 74-year old man with ST elevated myocardial infarction had VF rhythm and on-call physician performed CPR without confirming his code status. He had ROSC. After repeated discussion with him, the code status changed to full code. He was discharged with good neurological function.
We experienced 5 cases for whom CPR was performed even in the presence of DNR orders. Because the 3 cases out of them did not change code status, the initiation of CPR was thought to be inappropriate. The other 2 cases changed their code status into full code after the event. The decision of DNR order was thought to be inappropriate. We need to confirm the code status with patients and their family through adequate discussion before ordering DNR; otherwise, DNR order might be inadequate and harmful. We also make a new system for on-call physicians to be aware of the code status even when their primary physicians are not at the bed side in the event of CPA to prevent undesired CPR.
To cite this abstract:Endo, K; Hiraoka, E; Naito, T; Fujitani, S . THE INCIDENCE RATE AND CAUSE OF NON-COMPLIANCE OF THE DNR ORDERS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 292. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/the-incidence-rate-and-cause-of-non-compliance-of-the-dnr-orders/. Accessed April 1, 2020.