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Early DNR orders do not seem to affect medical resource use

Do-not-resuscitate orders (DNRs) issued 24 or more hours after hospital admission (delayed DNRs) seem to serve more as a medical "last rites" and are a marker rather than a cause of higher costs, concludes a study by K. Eric De Jonge, M.D., of Johns Hopkins University School of Medicine. Dr. De Jonge and colleagues found that DNR orders written at admission (admission DNRs) and delayed DNRs had different economic outcomes. Patients with delayed DNRs had longer hospital stays, higher mortality, and greater total costs, but daily costs were similar to those for patients with admission DNRs and patients without DNRs (full code).

The greater costs associated with delayed DNRs are probably due more to the patient's clinical deterioration and longer hospitalization than to the DNR order itself, explains Dr. De Jonge. In the study supported by the Agency for Health Care Policy and Research (National Research Service Award F32 HS00075), the researchers identified 265 terminally ill patients with illnesses such as AIDS and unresectable lung cancer. They compared their hospital costs and lengths of stay with admission DNRs, delayed DNRs, or no DNRs.

Admission DNR patients had a shorter length of stay (9.5 days vs. 12.8 days), lower total hospital costs ($6,861 vs. $9,334), and equivalent daily costs ($712 vs. $709) compared with all patients who were admitted without DNRs (full code and delayed DNR patients). Patients whose orders remained full code throughout the hospital stay had similar lengths of stay, total hospital costs, and daily costs as patients with admission DNRs. These equivalent costs suggest that early DNR orders do not affect medical resource use.

See "The timing of do-not-resuscitate orders and hospital costs," by Dr. De Jonge, Daniel P. Sulmasy, M.D., Ph.D., Karen G. Gold, Ph.D., and others, in the March 1999 Journal of General Internal Medicine 14, pp. 190-192.

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