Clinicians use the do-not-resuscitate (DNR) order not only as a guide for therapeutic decisions during a cardiopulmonary arrest but also as a surrogate for broader treatment directives, according to a study in JAMA Pediatrics by Amy Sanderson M.D., of Boston Children's Hospital, M.A., and colleagues.
A total of 107 physicians and 159 nurses responded to a survey regarding their attitudes and behaviors about DNR orders for pediatric patients. There was substantial variability in the interpretation of the DNR order. Most clinicians (66.9 percent) reported that they considered that a DNR order indicated limitation of resuscitative measures only on cardiopulmonary arrest. In reality, however, more than 85 percent reported that care changes beyond response to cardiopulmonary arrest, varying from increased attention to comfort to less clinician attentiveness. In addition, most clinicians reported that resuscitation status discussions take place later in the illness course than is ideal, according to the study results.
"Interventions aimed at improving clinician knowledge and skills in advance care discussions as well as the development of orders that address overall goals of care may improve care for children with serious illness," the study concludes.
JAMA Pediatr. Published online August 26, 2013. DOI: 10.1001/jamapediatrics.2013.2204