title: Association between Do Not Resuscitate/Do Not Intubate Status and Resident Physician Decision-making. A National Survey.
abstract: BACKGROUND
  Compared with their Full Code counterparts, patients with do not resuscitate/do not intubate (DNR/DNI) status receive fewer interventions and have higher mortality than predicted by clinical characteristics.
  
  
  OBJECTIVE
  To assess whether internal medicine residents, the front-line providers for many hospitalized patients, would manage hypothetical patients differently based on code status. We hypothesized respondents would be less likely to provide a variety of interventions to DNR/DNI patients than to Full Code patients.
  
  
  METHODS
  Cross-sectional, randomized survey of U.S. internal medicine residents. We created two versions of an internet survey, each containing four clinical vignettes followed by questions regarding possible interventions; the versions were identical except for varying code status of the vignettes. Residency programs were randomly allocated between the two versions.
  
  
  RESULTS
  Five hundred thirty-three residents responded to the survey. As determined by Chi-squared and Fisher's exact test, decisions to intubate or perform cardiopulmonary resuscitation were largely dictated by patient code status (>94% if Full Code, <5% if DNR/DNI; P < 0.0001 for all scenarios). Resident proclivity to deliver noninvasive interventions (e.g., blood cultures, medications, imaging) was uniformly high (>90%) and unaffected by code status. However, decisions to pursue other aggressive or invasive options (e.g., dialysis, bronchoscopy, surgical consultation, transfer to intensive care unit) differed significantly based on code status in most vignettes.
  
  
  CONCLUSIONS
  Residents appear to assume that patients who would refuse cardiopulmonary resuscitation would prefer not to receive other interventions. Without explicit clarification of the patient's goals of care, potentially beneficial care may be withheld against the patient's wishes.
authors.affiliation: 1 Division of Pulmonary and Critical Care Medicine, North Shore Medical Center, Salem, Massachusetts.
authors.forename: Elizabeth K
authors.initials: EK
authors.lastname: Stevenson
authors.affiliation: 2 Section of Critical Care Medicine, Virginia Mason Medical Center, Seattle, Washington.
authors.forename: Hashim M
authors.initials: HM
authors.lastname: Mehter
authors.affiliation: 3 The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts.|4 Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Walkey
authors.affiliation: 3 The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts.|5 Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.
authors.forename: Renda Soylemez
authors.initials: RS
authors.lastname: Wiener
mesh_terms: D000328:Adult; D000066491:Clinical Decision-Making; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D007442:Intubation, Intratracheal; D008297:Male; D010818:Practice Patterns, Physicians'; D016414:Resuscitation Orders; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: DNR/DNI; clinician decision-making; effect of code status