Study highlights differing perceptions of “do-not-resuscitate” orders

When patients have a do-not-resuscitate (DNR) order, it means they have chosen not to receive cardiopulmonary resuscitation (CPR). But hospital nurses report significant variations in the way DNR orders are perceived or acted on in clinical practice, reports a survey study in the January issue of the American Journal of Nursing (AJN). The journal is published in the Lippincott portfolio by Wolters Kluwer.

"While the definition of DNR might seem straightforward, its interpretation in clinical practice can be complicated," according to the new research, led by Patricia A. Kelly, DNP, APRN, AGN-BC, AOCN, of Texas Health Presbyterian Hospital of Dallas, and Kathy A. Baker, PhD, APRN, ACNS-BC, FCNS, FAAN, of Harris College of Nursing and Health Sciences at Texas Christian University.

Differing perceptions of DNR orders may lead to unintended consequences

Do-not-resuscitate orders have been a part of healthcare for more than 40 years. Published guidelines define DNR in terms of deciding to withhold CPR only, however, studies have shown healthcare providers and patients may be confused about the meaning and implications of DNR orders. An American Nurses Association position statement (PDF link) emphasizes that "patients with do-not-resuscitate orders must not be abandoned, nor should these orders lead to any diminishment in quality of care."

Based on her experiences, clinical nurse Karen Hodges, BSN, RN, OCN wondered, "How do nurses understand and act on DNR orders?" In response, Drs. Kelly, Baker, and colleagues performed a survey and interviews with 35 hospital nurses involved in caring for patients with DNR orders.

Analyzing the responses, the researchers identified one major theme: "Varying interpretations of DNR orders among nurses were common, resulting in unintended consequences." Within this overarching theme, there were three key subthemes:

• While the nurses provided clear definitions of DNR, they gave varying interpretations of the specifics of care. For example, while nurses agreed that DNR meant no CPR, some interpreted it as meaning no other aggressive lifesaving measures.
• The nurses reported situations where healthcare team members disagreed about how DNR orders affected clinical care and responsibilities. One nurse pointed out that having a DNR doesn't mean the person is a hospice patient: "It doesn't mean that you're not going to do everything that you would for anybody else."
• The nurses encountered family conflicts and confusion about DNR orders, particularly when the patient's condition changed, and patients and family members sometimes disagreed about DNR status.

These differing perceptions have the potential to affect care in many ways, including varying responses when the patient's condition deteriorates, tensions among team members, and differences in role expectations. "Lack of clarity and agreement about what DNR means in practice has a far-reaching impact," Dr. Kelly and colleagues write. "It's critical for nurses to understand that DNR orders do not substitute for plans of care."

Everyone - nurses, physicians, and families - needs to be on the same page in understanding the level of care a patient will receive."

Maureen Shawn Kennedy, MA, RN, FAAN, editor in chief, AJN

Dr. Kelly, Baker, and coauthors believe that nurses play a key role in making sure that patients, families, and healthcare providers have a clear understanding of what DNR orders mean - and what they don't mean. "In every setting, nurses have opportunities to clarify such misinterpretations through practice, education, advocacy and policy, and research," the researchers conclude. "After 40 years as one of the most widely recognized medical abbreviations, DNR should mean 'do not resuscitate,' not an acronym that may diminish care."