TEXAS — Patients with do-not-resuscitate (DNR) orders have higher death rates for unrelated illnesses because health care providers give less care, according to numbers from the American Heart Association, Harvard Medical School, and others. An e7Health study analyzed data from 10 institutions and found hospitals administer fewer blood tests, IVs and routine procedures that extend lives to people who have signed a DNR order.

Multiple studies have connected the presence of DNR orders to elevated death rates, poorer medical care, and negative health outcomes. Some of the key findings in e7Health’s study include:

• DNR doubled the death rate for surgical patients: A Harvard Medical School study of patients undergoing elective procedures found that the presence of a DNR increased death rates despite no difference in disease rates. About 13% of patients with DNR orders in place died within the first 30 days after surgery compared to just under 6% for those without DNR orders, while DNR patients who survived had lower rates of most postoperative complications, including pneumonia, surgical site infection, and kidney failure.
• Death rates increased by 150% for DNR patients who had emergency vascular surgery: Those who had a DNR in place were more likely to experience graft failure (about 9% vs. about 2%), while 35% died within 30 days of surgery compared to 14% without a DNR. 
• Almost half of stroke victims who were designated DNR within the first 24 hours died in the hospital: A California study of people who had an intracerebral hemorrhage, a severe type of stroke, found that 47% of patients who had a DNR within the first day of admission died in the hospital, while only 13% survived hospitalization. 

The presence of a DNR does not indicate the patient would rather end their lives. Rather, a DNR or DNI (do not intubate) order means simply that the person does not wish to be revived and have their lives extended through heroic measures.

A Geriatric Society study on how medical professionals perceive cancer patients with DNR orders suggested that 11% of nurses and doctors agreed that DNR was synonymous with “comfort measures.”

A Journal of Clinical Oncology study on care received by geriatric patients found that the presence of a DNR order was associated with patients receiving less care overall, even when that care was not related to heroic measures or resuscitation. Patients with DNR orders were 7% less likely to have blood cultures drawn, 12% less likely to have a central IV line placed and 12% less likely to receive a blood transfusion.

Another study on internal medicine residents found that resident physicians were less likely to provide aggressive treatment to DNR patients like dialysis, surgical consultation or transfer to intensive care despite not having specific guidance from patients or their family members.

DNR orders apply only to cardiopulmonary resuscitation, also known as CPR. But this isn’t the only form of attempting to revive a person whose body is failing in some way. CPR involves chest compression or stimulation, but many people may consider a do-not-intubate order, or DNI, which means they do not want a breathing tube placed in their throats.

In hospitals, this is typically referred to as code status, and in the absence of advance directives, it’s typical for all patients to receive “full-code” status, meaning that if their hearts or breathing stopped, all possible measures would be taken to save their lives.

No single national DNR standard exists for health care providers, and this variation means that even within the same city, patients at different hospitals can receive wildly different care.

The California DNR stroke study also sought to quantify the differences in how hospitals and medical facilities handle DNR patients. Researchers found that DNR rates, meaning the percentage of patients with such orders, varied between 0 and 70% and that services received in hospitals that use DNR orders 10% more frequently than similar facilities resulted in a 13% increase in the odds that the patient would die.

Just as no single medical standard exists for advance directives like DNR or DNI orders, no one legal standard applies across the country, either. While most states have laws on the books, orders may not be honored between states, and other differences can make it difficult to ensure that the patient’s wishes are followed.

For example, in Virginia, a DNR order cannot be suspended temporarily, even in cases where the person would need to undergo necessary surgery. Instead, the patient must revoke their existing DNR and write a new one, but patients may not be aware of this and may not have both orders. And in Florida, a DNR must be printed on yellow paper to be considered legally valid. 

In-hospital do-not-resuscitate orders in Texas were relatively loose until April 2018. With Texas Gov. Greg Abbott signing into law Senate Bill 11, both the meaning of a DNR order and the circumstances in which it can be entered became more tightly defined. Before introducing SB 11, it was technically possible for a physician to enter a DNR order without a patient’s or surrogate’s consent. But now, physicians must be careful their patients meet certain criteria to avoid being at legal risk for criminal misdemeanor. 

Important aspects of this law include who can enter the order and how the documentation of this emotion-laden decision must be carried out. DNR orders can only be entered by attending physicians.

The law also made it mandatory for hospitals to acquire a written and dated directive from either the competent patient or a surrogate decision-maker on the patient’s behalf. Patients or their family members are expected to sign the document affirming their decision for DNR status, which may elicit even more emotion at a time when an already difficult decision is being made. There is no requirement for a written directive from pediatric patients. 

A provision remains in the law such that, if a patient’s death is “imminent” (no definition is given), regardless of whether CPR was provided, and the DNR order is “medically appropriate,” a physician’s “reasonable medical judgement” can be used to enter a DNR order as long as that patient has not conveyed directions against a DNR order at any time when the patient was still competent. 

In contrast to the stringent requirements set forth to enact a DNR order for a patient, it will remain relatively easy to rescind the DNR order. Verbal revocation by the patient, guardian, or surrogate decision-maker to any care provider is all that is necessary to undo a DNR order, which is in stark contrast to the requirements for witnesses and signed documentation to enact the order.