Questions raised on DNR orders and shorter hospital stays

Over the past decade, time spent in-hospital has declined dramatically, even for patients with serious illnesses. This trend raises concern that increasing numbers of patients may be discharged before their conditions are stable, particularly if a do-not-resuscitate (DNR) order has been written.

A Northwestern University study of Medicare patients hospitalized with pneumonia, heart attack and stroke found that death rate after hospital discharge increased up to 72 percent between 1991 and 1997 for patients who had a DNR order written on the first or second day of their hospital stay.

However, for patients who did not have a DNR order, mortality during the 30 days after discharge generally remained stable. The study, published in the March 9 issue of the Archives of Internal Medicine, was led by David Baker, M.D., associate professor of medicine and chief of internal medicine at the Feinberg School of Medicine at Northwestern University and the Northwestern Medical Faculty Foundation.

It should be noted that, overall, Baker and his colleagues found little evidence that shorter length of stay actually caused the increase in post-discharge death for patients who had a DNR order.

The researchers also believe that their findings provide some reassurance that it is possible to reduce length of stay without jeopardizing the health of patients.

"Improvements in therapies, more rapid administration of effective therapies, greater willingness to evaluate some medical problems in the outpatient setting, ore efficient discharge practices and expanded use of home health care could all contribute to shorter mean lengths of stay without cutting corners," Baker said.

Baker also said that the increasing post-discharge death rate in patients with early DNR orders could reflect positive changes in end-of-life care, such as more widespread use of hospice, or could indicate a decline in the quality of care for terminally ill patients.

The researchers caution that additional studies are needed to examine whether there has been a decline in in-hospital quality of care for patients with DNR orders.

Collaborating on this study were Doug Einstadter, M.D., Scott S. Husak, and Randall D. Cebul, M.D., of Case Western Reserve University, Cleveland, Ohio.

The study was funded by a grant from the Agency for Healthcare Research and Quality.

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