Timing of Do-Not-Resuscitate Orders for Hospitalized Older Adults Who Require a Surrogate Decision-Maker

Authors

  • Alexia M. Torke MD, MS,

    1. From the Center for Aging Research, Regenstrief Institute; Division of
    2. General Internal Medicine and Geriatrics
    3. Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana
    Search for more papers by this author
  • Greg A. Sachs MD,

    1. From the Center for Aging Research, Regenstrief Institute; Division of
    2. General Internal Medicine and Geriatrics
    Search for more papers by this author
  • Paul R. Helft MD,

    1. Melvin and Bren Simon Cancer Center
    2. Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana
    Search for more papers by this author
  • Sandra Petronio PhD,

    1. School of Nursing
    2. School of Informatics, Indiana University, Indianapolis, Indiana
    3. Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana
    4. Department of Communication Studies, Indiana University—Purdue University Indianapolis, Indiana.
    Search for more papers by this author
  • Christianna Purnell,

    1. From the Center for Aging Research, Regenstrief Institute; Division of
    Search for more papers by this author
  • Siu Hui PhD,

    1. From the Center for Aging Research, Regenstrief Institute; Division of
    2. Biostatistics, School of Medicine
    Search for more papers by this author
  • Christopher M. Callahan MD

    1. From the Center for Aging Research, Regenstrief Institute; Division of
    2. General Internal Medicine and Geriatrics
    Search for more papers by this author

  • This research was presented in part at the National Meeting of the Society of General Internal Medicine, Minneapolis, Minnesota, April 27 to May 1, 2010.

Address correspondence to Alexia Torke, IU Center for Aging Research, 410 W, 10th St., Indianapolis, IN 46202. E-mail: atorke@iupui.edu

Abstract

OBJECTIVES: To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions.

DESIGN: Retrospective cohort study.

SETTING: Large, urban, public hospital.

PARTICIPANTS: Hospitalized adults aged 65 and older over a 3-year period (1/1/2004–12/31/2006) with a DNR order during their hospital stay.

MEASUREMENTS: Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders.

RESULTS: Of 668 patients, the ordering physician indicated that the DNR decision was made with the patient in 191 cases (28.9%), the surrogate in 389 (58.2%), and both in 88 (13.2%). Patients who required a surrogate were more likely to be in the intensive care unit (62.2% vs 39.8%, P<.001) but did not differ according to demographic characteristics. By hospital Day 3, 77.6% of patient decisions, 61.9% of surrogate decisions, and 58.0% of shared decisions had been made. In multivariable models, the number of days from admission to DNR order was higher for surrogate (odds ratio (OR)=1.97, P<.001) and shared decisions (OR=1.48, P=.009) than for patient decisions. The adjusted hazard ratio for hospital death was higher for patients with surrogate than patient decisions (2.61, 95% confidence interval (CI)=1.56–4.36). Patients whose DNR orders were written on Day 6 or later were twice as likely to die in the hospital (OR=2.20, 95% CI=1.45–3.36) than patients with earlier DNR orders.

CONCLUSION: For patients who have a DNR order entered during their hospital stay, order entry occurs later when a surrogate is involved. Surrogate decision-making may take longer because of the greater ethical, emotional, or communication complexity of making decisions with surrogates than with patients.

Ancillary