`DO NOT RESUSCITATE': HOW? WHY?AND WHEN?

URSULA SKERRITT1� AND BRICE PITT2

1Senior Registrar, Intensive Care Unit, Park Royal Centre for Mental Health, London, UK2Professor of Old Age Psychiatry, Academic Department of Psychiatry of Old Age,

St Mary's Hospital Medical School, London, UK

SUMMARY

Objective. The main objective was to discover who had `Do Not Resuscitate' (DNR) status, why, how, when and bywhom these decisions were made.

Design, setting and patients. The medical and nursing notes of all inpatients (139) (age range 16±100 years) in aninner city district general hospital on a single day were examined to determine the resuscitation status, age, sex anddiagnosis of each patient.

Result. A decision not to resuscitate had been taken in 28 (20%) of the cases. `Do Not Resuscitate' (DNR) patientswere signi®cantly older and more likely to su�er from malignant and cardiorespiratory disease. Patients withdementia and other psychiatric disorders were not signi®cantly more often labelled DNR. Evidence of consultationfor these decisions was lacking and the recording erratic.

Conclusions. (1) There is a great need to devise and implement comprehensive guidelines. (2) There is need forappropriate and comprehensive documentation outlining the reasons why and how the decision was taken, who wasconsulted and review date. (3) This is an important area for audit. # 1997 by John Wiley & Sons, Ltd.

Int. J. Geriat. Psychiatry, 12: 667±670, 1997.No. of Figures: 1 No. of Tables: 4 No. of References: 27

KEY WORDSÐDo Not Resuscitate (DNR); guidelines; cardiopulmonary resuscitation (CPR)

Despite attempts to bring order and consistency to`Do Not Resuscitate' decisions in the UnitedKingdom (Reid, 1990; Doyal and Wilsher, 1993,1994; BMA, 1993) comparable to those whichlargely prevail in the United States of America(Lo and Steinbrook, 1983), the policies in manyhospitals are still informal and even idiosyncratic(Stewart et al., 1990).

Several studies (Bedell et al., 1983; Ta�et et al.,1988) have shown that patients with malignancyand sepsis rarely survive to discharge after cardio-pulmonary resuscitation (CPR) although survivalrates overall vary from 0 to 28% with studies in theelderly showing poorer rates (Murphy et al., 1989).It has been argued that it is the burden of illnessrather than age which in¯uences outcome. Thereappears to be a greater proportion of patients withdementia under DNR orders and this may be

consequent on poor perceived quality of life(Pearlman and Uhlmann, 1991). It is suggestedthat DNR orders should be placed in the context ofpositive supportive care (Hignett et al., 1995).

In this study we look at who received DNRorders and how such decisions were taken andrecorded in an inner city district hospital.

METHOD

The case notes and nursing notes of all medicalinpatients were examined on one day. Age, sex,diagnosis, resuscitation status and hospital day onwhich the decision was taken were noted.

RESULTS

There were 139 patients with an age range of16±94 years, 28 (20%) of whom appeared not to befor resuscitation. The principal diagnoses are listed

�Correspondence to: Dr U. Skerritt, Intensive Care Unit, ParkRoyal Centre for Mental Health, Acton Lane, LondonNW10 7NS, UK.

CCC 0885±6230/97/060667±04$17.50 Received 15 February 1996# 1997 by John Wiley & Sons, Ltd. Accepted 30 September 1996

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 12: 667±670 (1997)

in Table 1. Patients with cardiorespiratory diseaseand malignancies were signi®cantly more likely tohave a `Do Not Resuscitate' (DNR) order whereasthose with cerebrovascular and psychiatric illness,including dementia, were not.

DNR patients were signi®cantly older (Fig. 1),age 81±84 years (CI 77.83±84.94), compared with76.3 (CI 76.66±78.94) �t � 2:123; p < 0:03�.

At follow-up via hospital records (at 3 months)(Table 2) signi®cantly more `DNR' than `no DNR'had died; almost two-thirds had been dischargedand this was not signi®cantly di�erent from thosewho were for resuscitation. There was no signi®cantdi�erence between the numbers still in hospital.

It was not always easy to ®nd DNR in the casenotes and in four cases (Table 3) it could not befound at all although nursing sta� stated thatthese patients were DNR. In only two cases wasthere mention of discussion with the relatives andin only one case was the reason for the decisionnot to resuscitate stated. Otherwise, not only wasit unclear why such decisions had been taken insome cases but still less clear why they had not inothers.

In 21% of cases the decision not to resuscitatewas taken on the day of admission and in a further53% within 1 week (Table 4). The DNR decisionwas reviewed in the case notes of only one patient.

Table 1. Principal diagnoses of patients

No. of pts (%) with No. of pts (%) Statistical signi®cance

DNR orders not DNR

N � 28 N � 111

Cardiorespiratory disease 11 (39) 15 (13) w2 � 9:76 p < 0:01Cardiovascular disease 3 (11) 27 (24) w2 � 2:45 p < 0:5Malignancies 6 (21) 3 (3) w2 � 12:95 p < 0:001Other 8 (29) 66 (60)

Concomitant psychiatric illness 5 18 w2 � 0:044 p > 0:5Concomitant dementia 4 14 w2 � 0:055 p > 0:5

Fig. 1. Age distribution

INT. J. GERIAT. PSYCHIATRY VOL. 12: 667±670 (1997) # 1997 by John Wiley & Sons, Ltd.

668 U. SKERRITT AND B. PITT

DISCUSSION

Some of the DNR decisions in this study seemarbitrary, but this may be due to the fact thatseverity of illness was di�cult to establish from thecase notes. There was uncertainty about who hadbeen consulted and di�culty in ®nding the decisionin the case notes.

The grouping of patients in broad diagnosticcategories may not re¯ect accurately the reasons forDNR. The high proportion of patients with malig-nant disease labelled DNR is understandable. Thediagnosis of dementia merited a DNR order inonly 21% of cases, unlike previous studies (Pearl-man et al., 1991). However, the severity of thedementia and quality of life were not measured(Zweibel, 1988). This is an area of concern for thefuture with the growing numbers of dementiasu�erers. Detailed guidelines (Doyal and Wilsher,1993) fail to deal with the issues of DNR in thosepatients with severe cognitive impairment andawait further clari®cation. Perceived quality of lifeis an important issue (Uhlmann and Pearlman,1991) in deciding DNR and age is regarded asassociated with a negative outcome in some studies(Bedell et al., 1983; Linn and Yurt, 1970; Ta�etet al., 1988; Peat®eld et al., 1977; Hershey andFisher, 1982; Fusgen and Summa, 1978; Bayeret al., 1985; Saphir, 1968; Gulati et al., 1983) whileothers report that age has no e�ect (Alexandrov,1995; Tresch, 1994; Rogove, 1995). There is alsothe moral/ethical consideration (Tomlison andBrody, 1990) in relation to duty of care. Fromour study it is obvious there is a need for moreformal and comprehensive guidelines to be ac-cepted and implemented (Doyal andWilsher, 1993;Miles et al., 1982).

The decision not to resuscitate is important andshould take note of the patient's previouslyexpressed and/or current implied wishes, religion,the views of family and signi®cant others, thegeneral practitioner, the prognosis for survival andquality of life. In the USA explicit views are

sought and advance directives accepted (Emanuel,1991). Hasty and impulsive decisions by one ortwo junior members of the clinical team with littleor no knowledge of the patient are unacceptable(Chief Medical O�cer, 1991) and suggestions tothe contrary (Skinner, 1993) should be discour-aged. Instead the decision should not be takenuntil due consideration can be given to the abovefactors and discussion with nursing sta� has takenplace (Jones et al., 1993; Thurtle and Cu�, 1993).The decision, once taken, should not be regardedas immutable but reviewed in the light of thepatient's progress. It is conceded that there aredi�culties in A � E departments (Wardrope andMorris, 1993), ICU and in other acute situations,but the practice of old age psychiatry with mainlyelective admissions and day hospital placementsshould allow time to make informed DNRdecisions about all patients including those whosu�er from dementia.

Table 2. Outcome at 3 months

No. of pts (%) with No. of pts (%) Statistical signi®cance

DNR orders not DNR

N � 28 N � 111

Still in hospital 3 (11) 13 (12) w2 � 0:026 p > 0:5Died 8 (28) 8 (7) w2 � 10:019 p < 0:01Discharged 17 (61) 89 (81) w2 � 4:68 p < 0:05

Table 3. Location of DNR documentation

No. of pts (%)

Medical and nursing notes 15 (54)

Medical notes only 1 (4)

Nursing noticeboard plus medical notes 4 (14)

Nursing board only 4 (14)

Unable to locate documentation 4 (14)

Total 28

Table 4. Hospital day decision taken

No. of DNR pts (%)

N � 28

Day 1 6 (21)

Day 2±7 15 (54)

Day 8±31 3 (11)

Unclear/unknown 4 (14)

Decision reviewed 2 (7)

# 1997 by John Wiley & Sons, Ltd. INT. J. GERIAT. PSYCHIATRY VOL. 12: 667±670 (1997)

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