Conceptually, "do not resuscitate" orders are straightforward medical documents. However, confusion among medical staff can lead to inappropriate care or patient harm, The New York Times reported Aug. 26.
In the 1960s, "resuscitation" referred primarily to CPR, but by the '90s, medical literature began using the term as a catchall for other medical interventions that would be to bring back a patient outside of cardiac arrest. The scope of the standard DNR did not change, but liberal usage of "resuscitation" created confusion, leading some physicians to administer or withhold care differently according to their interpretations.
Some research found that patients with DNR orders may not have received lifesaving treatment even before cardiac arrest and mortality rates are worse for DNR patients. Some clinicians interpret DNR orders as declining necessary treatment, leading them to withhold interventions such as transfusions, antibiotics and dialysis.
A 2017 survey of 553 residents found 41% said they would not transfer a DNR patient to the ICU and 62% said they would not have administered dialysis to a DNR patient. Some said they would not order diagnostic tests even if these procedures are permitted under the order.
"Do not resuscitate does not mean do not treat," Mathew Pauley, a bioethicist at Oakland, Calif.-based Kaiser Permanente, told the Times.
The majority of patients with a DNR are older adults with severe underlying medical conditions. Some research estimated that between 10% and 20% of hospitalized adults have a DNR, with those older than 85 being four times as likely to have one compared to adults younger than 65, according to the Times.
Because resuscitation lacks a clear definition, some health systems are clarifying the language of DNR orders to "do not attempt resuscitation" or "allow natural death."