The odds of patients in California having a do-not-resuscitate order written within 24 hours of a hospital admission depends on the facility's size, location and "technological bent," according to a study published in the current issue of the Archives of Internal Medicine.
Specifically, in a review of records for nearly 820,000 patients age 50 and older at 386 hospitals in 2000, David Zingmond, M.D., a University of California Los Angeles assistant professor of medicine, found a 10-fold variation across counties for DNR use.
DNR orders were less likely to be written for patients at for-profit or academic hospitals. Patients in rural areas used DNR orders at the highest rates, though Zingmond said variations did not correspond well to county population, hospital bed availability or population density.
"I think the two most important findings are that there is a large amount of variation in the use of do-not-resuscitate orders across California, and that indicates that it appears there is not a consensus on how to implement the orders across the state," Zingmond said. "(It's not that) people in one part of the state (are) 10 times sicker."
One explanation for the low use of DNR orders at large, academic medical centers is that people go there specifically for the life-saving procedures those institutions offer, Zingmond said.
"They didn't come here with the purpose and expectation that we aren't going to do everything," he said. "They came here with the opposite expectation."
Although implementing a DNR order is ultimately up to patients, Zingmond said physicians have a responsibility to initiate the conversation. The fact that small and rural hospitals had higher rates of DNR use could be linked to existing doctor-patient relationships that make it easier to bring up difficult topics in conversation, he said.
Zingmond recommended that discussing DNR preferences be included in quality-measurement guidelines and that physician mentors have residents or medical students accompany them when DNR discussions are initiated with patients or their families so physicians-in-training can learn by observing.
Read the study abstract.