More than half of do-not-resuscitate (DNR) orders were completed by a surrogate decision maker in a recent study at one urban, public hospital.
The retrospective cohort study was based on an electronic chart review of 668 patients who got a DNR while in the hospital. The decision was made by the patient in 191 cases (28.9%), a surrogate in 389 cases (58.2%) and as a shared decision by both parties in 88 cases (13.2%). Decisions made by surrogates were typically made later in a patient's hospital course. On hospital day three, 77.6% of patient decisions, 61.9% of surrogate decisions, and 58.0% of shared decisions had been made. Perhaps in part due to this delay, surrogate decisions were also made closer to a patient's death—a median of 1.0 days before death, compared to 3.5 days for patient decisions and 4.0 days for shared decisions. Surrogate decisions were more likely to be made for patients in the ICU than those in the regular wards (62.2% vs. 39.8%, P<0.001).
Based on the results, researchers suggested that surrogate decision making is the norm rather than the exception. They recommended that research and policies relating to DNRs take these results into account and incorporate best practices in surrogate communication, rather than assuming an autonomous patient. The finding that surrogate decisions were made later may relate to previous research showing that surrogate decision making is a process requiring multiple conversations. Prior research has also found that delayed DNR decisions are associated with higher hospital costs and longer lengths of stay, the researchers noted. Later decisions also could reduce the time available to provide end-of-life care.
Although the study's generalizability is limited by its single setting, other researchers may want to consider the findings and identify the causes of the delays in surrogate decision making. Interventions should be developed to optimize the decision making process for surrogates, the study authors concluded. The study was published in the July Journal of the American Geriatrics Society.
ACP Hospitalist ran a cover story on DNRs in its June issue.