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The 1990 Patient Self-Determination Act (PSDA) requires hospitals, skilled nursing facilities, and other health care settings to develop written policies concerning advance directives, including do-not-resuscitate (DNR) orders. They must include such directives in the patient's chart and inform patients about their right to prepare such documents.
The purpose of the PSDA was to increase patient involvement in decisions about life-sustaining treatments while they were still competent to do so. However, overall use of DNR orders in hospitals in Northeast Ohio has changed relatively little since passage of the PSDA, according to a study supported by the Agency for Healthcare Research and Quality (HS09969).
According to the researchers, there was an initial increase between 1991 and 1992 in the use of early DNR orders (first 2 hospital days), but this effect was counteracted by decreasing use of late DNR orders during the same period. Mortality rates 1 month after preparation of a DNR order remained stable for five conditions, after adjusting for risks of death. This suggests that there were no dramatic changes in quality of care or aggressiveness of care for patients with DNR orders. However, the 21 percent increased mortality for stroke patients with early DNR orders and 25 percent increase in mortality for those with late DNR orders warrants further examination, cautions lead investigator, David W. Baker, M.D., M.P.H., of Case Western Reserve University.
Dr. Baker and his colleagues analyzed early and late DNR orders abstracted from the medical charts of 91,539 Medicare patients hospitalized with heart attack, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke in 29 hospitals in Northeast Ohio. Risk-adjusted rates of early DNR orders increased by 34 to 66 percent between 1991 and 1992 for four of the six conditions and then remained flat or declined slightly between 1992 and 1997. Use of late DNR orders declined by 29 to 53 percent for four of the six conditions between 1991 and 1997. The declining rate of late DNR orders seen in this study and the increasing mortality rate among stroke patients with DNR orders should intensify concerns about possible quality-of-care problems for these patients, concludes Dr. Baker.
See "Changes in the use of do-not-resuscitate orders after implementation of the Patient Self-Determination Act," by Dr. Baker, Doug Einstadter, M.D., M.P.H., Scott Husak, B.S., and Randall D. Cebul, M.D., in the May 2003 Journal of General Internal Medicine 18, pp. 343-349.
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