title: Impediments to writing do-not-resuscitate orders.
abstract: BACKGROUND
  Physicians are frequently unaware of their patients' desires regarding end-of-life care. Consequently, opportunities to implement do-not-resuscitate (DNR) orders are often missed.
  
  
  OBJECTIVE
  To determine the reasons attending physicians do not write DNR orders when patients face increased mortality.
  
  
  METHODS
  Over 4 months, the medical records of all inpatients on the General Medicine Service were reviewed at the time of discharge to identify patients with conditions predicting increased mortality. These cases were presented to a 5-member panel who decided if a DNR order was indicated. Reasons for missing DNR orders were discussed with the attending physicians.
  
  
  RESULTS
  Of 613 consecutive admissions, the panel identified 149 patients (24%) for whom DNR orders were indicated. In 88 (59%) of these, DNR orders were absent. The lack of a DNR order did not correlate with age (P = .95), sex (P = .61), or race (P = .80). The attending physicians' explanations for not writing DNR orders in these 88 cases included the belief that the patient was not in imminent danger of death (n = 49 [56%]), the belief that the primary physician should discuss DNR issues (n = 43 [49%]), and the lack of an appropriate opportunity to discuss end-of-life issues (n = 38 [43%]). In 11 (12%) of the 88 cases, patients or their families did not accept the recommendation for a DNR order. No physicians expressed concerns regarding the morality of DNR orders, discomfort discussing end-of-life issues, or the threat of litigation as reasons for not writing a DNR order.
  
  
  CONCLUSIONS
  Limitations in the extent and depth of the physician-patient relationship appear to be the most frequent impediments to writing DNR orders in our institution.
authors.affiliation: Department of Medicine, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA.
authors.forename: A H
authors.initials: AH
authors.lastname: Eliasson
authors.forename: J M
authors.initials: JM
authors.lastname: Parker
authors.forename: A F
authors.initials: AF
authors.lastname: Shorr
authors.forename: K A
authors.initials: KA
authors.lastname: Babb
authors.forename: R
authors.initials: R
authors.lastname: Harris
authors.forename: B A
authors.initials: BA
authors.lastname: Aaronson
authors.forename: M
authors.initials: M
authors.lastname: Diemer
mesh_terms: D000328:Adult; D032722:Advance Care Planning; D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D004219:District of Columbia; D035082:Federal Government; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D010817:Physician-Patient Relations; D016414:Resuscitation Orders; D012189:Retrospective Studies