A Prospective Trial of a New Policy Eliminating Signed Consent for Do Not Resuscitate Orders

• Published in: Journal of general internal medicine : JGIM Vol. 21; no. 12; pp. 1261 - 1268
• Main Authors: Sulmasy, Daniel P., Sood, Johanna R., Texiera, Kenneth, McAuley, Ruth L., McGugins, Jennifer, Ury, Wayne A.
• Format: Journal Article
• Language: English
• Published: Malden, USA Blackwell Publishing Inc 01.12.2006; Springer; Springer Nature B.V; Blackwell Science Inc
• Subjects: Biological and medical sciences; Blood products; Ethics; General aspects; Humans; informed consent; Internal medicine; Medical sciences; Miscellaneous; Nurses; Original; Personnel, Hospital; Physicians; Prospective Studies; Public health. Hygiene; Public health. Hygiene-occupational medicine; Resuscitation Orders; resuscitation policies; self efficacy; Stress; Surveys and Questionnaires; United States; North America; America; New York; United States > US; Intensive cardiocirculatory care; End of life decision; Advance directives; Trusted third party; Verbal communication; Stress; Printed form; Medicine; Prospective; resuscitation orders; Ethics; Health policy; Signing; Written communication; Self efficacy; Informed consent; Clinical trial; Public health; resuscitation policies
• ISSN: 0884-8734; 1525-1497
• DOI: 10.1111/j.1525-1497.2006.00612.x

BACKGROUND: Some institutions require patients and families to give signed consent for Do Not Resuscitate (DNR) orders, especially in New York State. As this may be a barrier to discussions about DNR orders, we changed a signed consent policy to a witnessed verbal consent policy, simplified and modified the DNR order forms, and educated the staff at 1 hospital, comparing the effects with an affiliated hospital where the policy was not changed. DESIGN: Prospective natural experiment with intervention and comparison sites. SUBJECTS AND MEASUREMENTS: Pre‐ and postintervention, we surveyed house officers' confidence and attitudes, reviewed charts to assess the number of concurrent care concerns (CCCs) addressed per DNR order (e.g., limits on intubation or blood products or need for hospice), and at the intervention hospital, measured the stress levels of surrogates consenting for DNR orders using the Horowitz Impact of Event Scale. We also surveyed staff perceptions about the policy following the change. RESULTS: At the intervention hospital, the percentage of house officers reporting low confidence in their ability to obtain consent for DNR orders declined postintervention (24% to 7%, P=.002), while there was no significant change at the comparison hospital (20% vs 15%, P=.45). Among intervention hospital house officers, there were declines in percent reporting difficulty talking to patients and families about DNR orders, but no significant changes at the comparison hospital. At the intervention hospital, the mean number of CCCs/DNR order increased (1.0 pre to 4.2 post, P<.001), but did not change significantly (1.2 pre to 1.4 post) at the comparison hospital. The mean total stress score for intervention hospital surrogates declined postintervention (23.6 to 17.3, P=.02), indicating lower stress. House officers (98%), attendings (59%), and nurses (79%) thought the new policy was better for families. CONCLUSIONS: The policy change was well received and associated with improved house officer attitudes, more attention to patients' concurrent care concerns, and decreased surrogate stress. The results suggest that DNR orders can be made simpler and clearer, and raise questions about policies requiring signed consent for DNR orders.