subject of attention objectives: Do-not-resuscitate (DNR) orders have been espoused for the enhancement of patient autonomy.

subject of attention objectives: Do-not-resuscitate (DNR) orders have been espoused for the enhancement of patient autonomy, avoidance of futile medical intervention, and charge containment. Outcomes of cardiopulmonary resuscitation (CPR) in the intensive care setting have been dismal, with hardly any patients surviving to discharge. This investigation compares patients who died in medical and surgical ICUs in a DNR status with those who died after attempted CPR Design: Retrospective chart review of all patients who died in the medical and surgical ICU in a 2-year period. Measurements and results: A total of 195 cases were reviewed during the specified time period; 108 patients had undergone attempted resuscitation, and 87 patients died in a DNR status. There were no significant differences when preadmission disability, source of admission, location (medical ICU v surgical ICU), chronic medical conditions, acute diagnosis, sex and weight were considered. Patients who were designated "DNR" were significantly older than patients who underwent CPR (mean age, 657 years v 589 years; p=0005) The DNR-designated patients were in general more harshly ill as measured with the APACHE II regularity (mean score, 23.5 vs 207; p = 0004) which was accounted for primarily on greater alterations in level of consciousness as measured with the Glascow Coma scale (mean score, 100 v 121; p = 0001) Conclusions: Among patients dying in the medical and surgical ICUS in the author? institution, no other than age and level of consciousness discriminated patients who died in a DNR status from those who died after attempted CPR

APACHE = Acute Physiology and Chronic Health Evaluation; CPR = cardiopulmonary resuscitation; DNR = do not resuscitate; GC = Glasgow Coma Scale

Do-not-resuscitate (DNR) orders have been in use for approximately sum of two units decades.[1-3] Arguments for their use include enhancement of patient autonomy, avoidance of futile medical interventions, and splendor containment.[4-6] The ICU is a setting where patients may be make submissiveed to expensive, painful, and dehumanizing medical interventions, especially in the course of and following attempted cardiopulmonary resuscitation (CPR) Numerous studies have demonstrated that in certain clinical situations CPR is almost always futile.[7-15] The physicians' task is to communicate his knowledge about the two the probable and possible issues of CPR to the patient and the patient's family and then to assist the patient (and/or the patient's family) in making informed decisions regarding resuscitation. The fundamental note to this process is early, effective communication between involved care-givers, the patient, and the patient's family Previous studies have examined the use of DNR orders the one and the other hospitalwide and within the intensive care setting.[16-18] To further define the use of DNR orders at our institution, we examined the characteristics of patients who died in the ICU setting who either were in a DNR status or had undergone attempted resuscitation.

Methods

We deportment ed a retrospective review of all patients who died in the medical or surgical ICUs at Walter Re Army Medical Center a university teaching hospital, during the 24-month period from January 1 1987 between the walls of December 31, 1988. The intent of this reflection was to define those patient characteristics that differentiated patients being giveed resuscitation (CPR) from those who were designated "DNR" in an ICU setting.

Cardiopulmonary arrest was defined as the abrupt cessation of cardiac or pulmonary function necessitating the initiation of CPR in an attempt to sustain life. elision seizures, and progressive respiratory failure were exclud as causes of arrest. The criteria for DNR status were a physician note and a written order conferring that status in succession the patient.

Cases were identified according to examination of the inpatient charts for all patients who died in the medical and surgical ICUs during the specified time period. We identified 206 cases; the records were reviewed in 195 cases and were unavailable in the remaining 11 cases. We identified 108 patients who died following attempted resuscitation. The charts of seven of these patients had insufficient data for analysis and were exclud We identified 87 patients who died in a DNR status with all charts available for examination. Resuscitations were deportment ed in accordance with advanced cardiac life support protocols by dint of an assigned "code team" consisting of a senior medical resident, an anesthesiologist, and a general surgeon or by means of the staff or housestaff of the ICU involved.

The initial resuscitation in the ICU was used for data collection upon those patients in whom resuscitation was attempted more than one time Patients who had undergone resuscitation and were subsequently assigned DNR status were included in the resuscitation arrange Data for those patients who died in a DNR status were abstracted at the time of the DNR order or note. We recorded demographic and clinical information onward each patient, including age, sex weight, admission source, functional status, and the acute and chronic diagnoses.

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