Racial variation in the use of do-not-resuscitate orders.
OBJECTIVE
To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample.


METHODS
Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82-0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates.


RESULTS
In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p <.001). Rates of orders were also lower ( p <. 001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower ( p <.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days.


CONCLUSIONS
The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.
Shepardson
L B
LB
Division of General Internal Medicine and Health Care Research, Cleveland VA Medical Center, Ohio, USA.
Gordon
H S
HS
Ibrahim
S A
SA
Harper
D L
DL
Rosenthal
G E
GE
D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D003657:Decision Making; D005260:Female; D006761:Hospitals; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009820:Ohio; D012372:ROC Curve; D016414:Resuscitation Orders; D012720:Severity of Illness Index; D044465:White People / Q000706:statistics & numerical data*