DNR dilemmas

An increasing number of U.S. patients enter “Do not resuscitate” orders in their health-care records. DNR is designed primarily to tell medical caregivers not to restart a stopped heart or revive a patient who has stopped breathing. It does not mean “Do not treat.” In most respects, DNR patients are entitled to the same care that others receive. Unfortunately, new research by a Yale team suggests they may not be getting it.

As many as 15 percent of DNR patients undergo surgery. But compared with non-DNR patients of similar health and age, people with DNR orders were 2.2 times more likely to die within 30 days of surgery, and they also had more complications and longer hospital stays, says Sanziana Roman, an endocrine surgeon at the Yale School of Medicine.

For a study in the Archives of Surgery. Roman, with Julie Ann Sosa and another Yale colleague, compared 4,128 DNR patients with an equal number of similar patients with no DNR orders. Most of the patients, who came from a database from over 120 U.S. hospitals, were white, female, and elderly. When researchers matched patients’ ages and surgical procedures and controlled for other health problems—such as diabetes, cancer, and heart disease—the presence of the order stood out clearly as a critical and independent risk factor for bad outcomes.

One reason for the poorer prognosis, says Roman, is that DNR patients have more serious medical problems prior to surgery. But the research raises the question of whether DNR has become a kind of self-imposed death sentence—an unspoken code for doctors to do less and give up sooner.

The data didn’t allow the researchers to confirm or dismiss that suspicion. But “it’s a possibility,” says Roman, adding that the study caused her to examine her own assumptions. “There clearly need to be better and earlier discussions between doctors and patients about life and death,” she says. “DNR patients have to understand these risks so they can make more-informed decisions.”