1. Health Care Delivery
EDITOR'S NOTE-The issues involving "no code" or "do not resuscitate" (DNR) orders are many and
complex. They are often of particular concern to younger physicians serving as house officers but are
of importance to any physician caring for a patient whose outlook is considered to be poor or hopeless.
The three articles presented in this mini-symposium describe the problem as addressed in three differ-
ent environments.
Do-Not-Resuscitate Orders in a
County Hospital
MARK R. LEVY, MD
MARY E. LAMBE, MD
CHARLES L. SHEAR, DrPH
San Bernardino, California
The use of the do-not-resuscitate order has be-
come accepted medical practice. To date, how-
ever, no studIy has been done of how often it is
used or factors associated with its use. Reports of
all deaths of inpatients occurring during calendar
year 1981 at San Bernardino County Medical Cen-
ter were eligible for study. Retrospective review
of the 237 cases indicated that a do-not-resusci-
tate order had been written for 165 (69.6%) of the
patients. Comparison of reports of those for whom
such an order had been written with those for
whom no order had been written indicated that a
do-not-resuscitate order was not associated with
age, sex, ethnicity or pay status. Indices of mental
clarity, however, were associated with orders not
to resuscitate; those patients residing in nursing
homes, and not alert and oriented on admission
were overrepresented in the group given this
order. Primary discharge diagnosis was also as-
sociated with such an order, as was an increased
duration of hospital stay.
(Levy MR, Lambe ME, Shear CL: Do-not-resusci-
tate orders in a county hospital [Health Care De-
livery]. West J Med 1984 Jan; 140:111-113.)
THE WRITING of a do-not-resuscitate order (defined
as a doctor's order to withhold cardiopulmonary re-
suscitative efforts in the event of acute cardiac or
respiratory arrest) has become an accepted practice in
the care of terminally ill patients.' General ethical
guidelines and considerations for the use of a do-not-
resuscitate order continue to be published in the medi-
cal literature.'-' To date, however, no study has been
done that describes the magnitude of this practice, the
patient factors that are associated with its use, its effect
on the quality of a patient's remaining life or its effect
on the use of costly inpatient health care services. Such
information would assist medical professionals to use
the do-not-resuscitate order in an ethical and cost-
effective manner. We describe a first attempt to esti-
mate the above-mentioned factors.
Patients and Methods
The cases of all patients who died during their hos-
pital stay at the San Bernardino County Medical Cen-
ter during the 1981 calendar year were identified retro-
spectively. The San Bernardino County Medical Center
Hospital is a teaching hospital of medium size (about
300 beds). Decisions not to resuscitate are not con-
trolled by a formal clinical care committee, but rather
by the house staff and attending physicians directly in-
volved in a patient's care.
Demographic information on patients was obtained
from medical records. The information collected in-
cluded age, sex, ethnicity and pay status-that is,
whether a patient was covered by MediCal, Medicare,
a third-party insurer or was personally responsible for
medical costs.
Two indices of a patient's mental clarity on admission
were used. These crude measures were place of resi-
dence before admission (private residence, nursing
home or other) and mental state on admission (alert
and oriented to time, place and person, or other) from
the admission history and physical. In addition to these
indices of function, the association between a do-not-
resuscitate order given during a prior admission and its
use in the terminal admission was assessed.
Measures of the course of hospital stay included
admitting service, number of days in hospital and pri-
mary cause of death. This latter information was ob-
tained from autopsy reports when available or from
discharge summaries. Diagnoses were coded into the
17 major categories of the International Classification
of Diseases (9th revision), Clinical Modification.
Additional information was collected to describe the
JANUARY 1984 * 140 * 1
From the Department of Family Medicine, University of California,
Irvine, and the Department of Family Practice, San Bernardino County
Medical Center, San Bernardino, California.
Reprint requests to Mark Levy, MD, Department of Family Practice,
San Bernardino County Medical Center, 780 East Gilbert Street, San
Bernardino, CA 92404.
ill

2. DO-NOT-RESUSCITATE ORDERS IN A COUNTY HOSPITAL
effect of a do-not-resuscitate order on a physician's
care of a patient and how family and friends interacted
with the patient. Considerations included narcotic use
(defined as the percentage of the number of days in
hospital for which any narcotic was given) and visit
days (defined as the percentage of days in hospital the
patient had a visitor as noted in the nursing notes).
To determine the association between the use of do-
TABLE 1.-Association Between Selected Demographic
Variables and a Do-Not-Resuscitate Order in 237 Patients
Do-Not-Resuscitate Order
Demographic Yes No
Characteristics N (%) N (%)
Age (years)
0- 9 ................ 14( 8.4) 6( 8.3)
10-29 ................ 15 ( 9.1) 8 ( 11.1)
30-49 ................ 12 ( 7.3) 13 ( 18.1)
50-69 ................ 50 ( 30.3) 17 ( 23.6)
70+ .............. 74 ( 44.8) 28 ( 38.9)
TOTAL ....... 165 (100.0) 72 (100.0)
Sex
Male ................ 98 ( 59.4) 42 ( 58.3)
Female .............. 67 ( 40.6) 30 ( 41.7)
TOTAL ....... 165 (100.0) 72 (100.0)
Ethnicity*
White ............... 118 ( 72.0) 43 ( 59.7)
Hispanic ............. 30 ( 18.3) 15 ( 20.8)
Other ................ 16 ( 9.7) 14 ( 19.5)
TOTAL ....... 164 (100.0) 72 (100.0)
Pay Status*
Medicare ............. 92 ( 57.9) 30 ( 46.1)
MediCal .............. 11 ( 6.9) 10 ( 15.4)
Self-pay .............. 45 ( 28.3) 20 ( 30.8)
Private-3rd party .......... 11 ( 6.9) 5 ( 7.7)
TOTAL .. 159 (100.0) 65 (100.0)
*Ethnicity and pay status totals reflect missing data for 1 and 13 pa-
tients, respectively.
TABLE 2.-Association Between Place of Residence,
Level of Consciousness on Admission and a
Do-Not-Resuscitate Order
Do-Not-Resuscitate Order
Yes No
Characteristics N (%) N (%)
Place of Residence*
Home/family ......... 89 ( 53.9)
Nursing home ......... 60 ( 36.4)
Other ................ 16 ( 9.7)
TOTAL ....... 165 (100.0)
Consciousness on Admission*
Alert and oriented to time,
place and person ..... 45 ( 27.4)
Other ................ 119 ( 72.6)
TOTAL ....... 164 (100.0)
55 ( 78.6)t
8 ( 11.4)t
7 ( 10.0)t
70 (100.0)t
28 ( 38.9)
44 ( 61.1)
72 (100.0)
*Place of residence and consciousness on admission reflect missing data
for 2 and 1 patients, respectively.
tP<.01.
not-resuscitate order and the above-mentioned factors,
deaths were divided into two groups; those that oc-
curred after such an order was issued and those for
which no do-not-resuscitate order was issued. An as-
sociation was tested using standard x2 and Student's
t tests.
Results
During calendar year 1981, 315 patient deaths were
recorded. Fifteen stillbirths were excluded from the
analysis. Of the remaining 300 patients, complete
charts were available for 237 (79% ). Only these cases
are included in the analysis.
Of the 237 eligible cases, 165 (69.6%) had a do-
not-resuscitate order written during their hospital stay.
Of the 165 cases, 81 (49.1%) had this order written
during the first two days of their hospital stay. On the
average, five hospital days elapsed between the time a
do-not-resuscitate order was written and the time a
patient died.
Demographic characteristics of the total sample were
as follows. More than 70% of the patients were 50
years of age or older, 59% were male, 68% were white
and 19% were Hispanic. Only 7% were covered by
private, third-party health insurance. Comparing de-
mographic characteristics of patients for whom a do-not-
resuscitate order was written with those for whom no
such order was written showed no statistically signifi-
cant associations with age, sex, ethnicity or pay status
(Table 1).
Comparison of the crude indices of mental clarity on
admission of the do-not-resuscitate order group indi-
cated that less functional patients were more likely to
have a do-not-resuscitate order. Place of residence was
associated with the decision not to resuscitate (P<.01),
with 88.2% of patients from nursing homes being in
that group. Those who were not alert and oriented to
time, place and person also tended to be overrepresent-
ed in the do-not-resuscitate group; however, statistical
significance was not reached (Table 2).
No admitting service tended to have more do-not-
resuscitate orders than any other. A striking finding
was that 100% of those patients with a no-code order
on prior admission had such an order on the terminal
admission, whereas 70% of those without a prior do-
not-resuscitate order had such an order on the terminal
admission (P<.05) (Table 3).
Primary discharge diagnosis was positively asso-
ciated with a written do-not-resuscitate order (P<.01).
Categories of diagnosis overrepresented in that group
included nonspecific signs and symptoms (primarily
septic shock), respiratory conditions (primarily pneu-
monia), intra-abdominal conditions (primarily renal
failure), infectious diseases (primarily septicemia),
neonatal distress (primarily due to extreme immaturity)
and neoplasms (Table 4).
The mean duration of hospital stay for those pa-
tients with a do-not-resuscitate order was 14.2 days
THE WESTERN JOURNAL OF MEDICINE112

3. DO-NOT-RESUSCITATE ORDERS IN A COUNTY HOSPITAL
(Table 5). For patients who had no such order written,
the mean duration was 7.9 days. This trend was statis-
tically significant. Neither the number of visits by
friends and family nor narcotic use was associated with
the presence of a no-code order. Moreover, these as-
TABLE 3.-The Association Between Order Not to
Resuscitate on Prior Admission, Current Admitting Service
and a Do-Not-Resuscitate Order in 237 Patients
Do-Not-Resuscitate Order
Yes No
Characteristics N (%) N (%)
Do-Not-Resuscitate Order
Given in Prior Admission*
Yes ................. 13 ( 8.3) 0 ( 0.0)t
No ................. 143 ( 91.7) 62 (100.0)t
TOTAL ....... 156 (100.0) 62 (100.0) t
Current Admitting Service
Medicine ............. 115 ( 69.6) 48 ( 66.7)
General surgery ....... 15 ( 9.1) 9 ( 12.5)
Neurosurgery ......... 10 ( 6.1) 6 ( 8.3)
Neonate intensive
care unit ........... 12 ( 7.3) 6 ( 8.3)
Other ................ 13 ( 7.9) 3( 4.2)
TOTAL ....... 165 (100.0) 72 (100.0)
*No prior admission for 19 patients.
tP <.05.
TABLE 4.-Association Between Primary Discharge
Diagnosis and a Do-Not-Resuscitate Order in 237 Patients
Do-Not-Resuscitate Order
Primary Discharge Yes No
Diagnosis Category* N (%) N (%)
Nonspecific signs
and symptoms ........ 12 ( 7.3) 1 ( 1.4)
Respiratory tract ........ 38 ( 23.2) 8 ( 11.1)
Gastrointestinal tract ..... 13 ( 7.9) 3 ( 4.2)
Genitourinary tract ...... 12 ( 7.3) 3 ( 4.2)
Infectious disease ....... 19 ( 11.6) 5 ( 6.9)
Neonatal distress ........ 10 ( 6.1) 3 ( 4.2)
Neoplasm .............. 8 ( 4.9) 3 ( 4.2)
All other .............. 12 ( 6.7) 6 ( 8.2)
Cardiovascular .......... 29 ( 17.7) 25 ( 34.7)
Injury/poisoning ........ 10 ( 6.1) 12 ( 16.7)
Metabolic/endocrine ..... 2 ( 1.2) 3 ( 4.2)
TOTAL ....... 165 (100.0) 72 (100.0)
*P<0.01.
TABLE 5.-Association Between Narcotic Use,
Visits By Outsiders, Duration of Hospital Stay and a
Do-Not-Resuscitate Order
Do-Not-Resuscitate Order
Yes No
Before After
Characteristics Order Order
Mean duration of hospital stay
(days) * ......... ........ 9.0 5.2 7.9
Narcotic use (%)t ..... ..... 14.5 13.9 13.8
Visits by outside persons* ..... 20.8 20.0 17.8
*P<.05 no do-not-resuscitate order.
tPercentage of mean days narcotic drug given to mean days in hospital.
$Percentage of mean days in which a visit occurred to mean days in
hospital.
pects of a patient's care did not change after a do-not-
resuscitate order was written (Table 5).
Discussion
Assuming that a formal decision not to resuscitate
indicates a patient is hopelessly ill, the high prevalence
of such orders in this study indicates that most deaths
that occur in this type of institution are not unexpected.
This study includes only deaths, so that the extrapola-
tion of this figure to all admissions is unwarranted. In
addition, as the data source was medical charts, their
validity is questionable. This is especially true for in-
formation on narcotic use and frequency of visitors.
However, as the error in information is likely to be
equal for the two groups of patients (do-not-resuscitate
order versus no such order), the direction of bias would
be toward no association.
These results indicate that demographic character-
istics of patients play a minor role in the decision to
write a no-code order. While no apparent trend of
sex, ethnicity or pay status was present, those in the
10- to 39-year-old age bracket were less likely to have
such an order written. The results indicate that the
do-not-resuscitate orders are being written in good
faith, without regard to sex, race or socioeconomic
status. The trend by age is most likely a result of the
severity of illness.
It appears that the ability of a patient to function
and a patient's prognosis play the greatest roles in the
decision to give a do-not-resuscitate order. This is
evidenced by the greater number of orders written for
nursing home residents, those who are not alert and
oriented on admission and those whose diagnosis car-
ries a poor prognosis.
The lack of change in number of visits received by
a patient or of administration of narcotics when a do-
not-resuscitate order was written does not indicate the
order's lack of effect on a physician or a patient's
family. These measures were crude indicators and of
questionable validity.
The duration of hospital stay was greater for those
patients for whom a do-not-resuscitate order was writ-
ten. While the natural history of disease experienced in
the two groups may account for the difference in dura-
tion of stay, these results do not support the theory
that no-code orders help avoid an unnecessary use of
expensive inpatient services. On the average, patients
with a do-not-resuscitate order survived for about five
days following the order's initiation.
REFERENCES
1. Massachusetts General Hospital, Clinical Care Committee: Optimum
care for hopelessly ill patients. N Engl J Med 1976 Aug 12; 295:362-364
2. Miles SH, Cranford R, Schultz AL: The do-not-resuscitate order in
a teaching hospital. Ann Intern Med 1982 May; 96:660--664
3. Suber DG, Tabor WJ: Withholding of life-sustaining treatment from
the terminally ill, incompetent patient: Who decides? JAMA 1982 Nov
19; 248:2431-2432
4. National Conference Steering Committee: Standards for cardiopul-
monary resuscitation and emergency cardiac care. JAMA 1974 Feb 18;
227(Suppl):837-868
5. Rabkin MT, Gillerman G, Rice NR: Orders not to resuscitate. N
Engl J Med 1976 Aug 12; 295:364-366
JANUARY 1984 * 140 * 1 113