Editing Do not resuscitate (section)

===Less care for DNR patients===

Reductions in other care are not supposed to result from a DNAPR decision being in place.<ref name="medline-dnr"/> Some patients choose DNR because they prefer less care: Half of Oregon patients with DNR orders who filled out a [[POLST]] (known as a Physician Orders and Scope of Treatment, or POST, in Tennessee) wanted only comfort care, and 7% wanted full care. The rest wanted various limits on care, so blanket assumptions are not reliable.<ref name="tolle-2015">{{Cite journal |last1=Tolle |first1=Susan W. |last2=Olszewski |first2=Elizabeth |last3=Schmidt |first3=Terri A. |last4=Zive |first4=Dana |last5=Fromme |first5=Erik K. |date=2012-01-04 |title=POLST Registry Do-Not-Resuscitate Orders and Other Patient Treatment Preferences |journal=JAMA |volume=307 |issue=1 |pages=34–35 |doi=10.1001/jama.2011.1956 |pmid=22215159 |issn=0098-7484|doi-access=free }}</ref> There are many doctors "misinterpreting DNR preferences and thus not providing other appropriate therapeutic interventions."<ref name="fendler"/>

Patients with DNR are less likely to get medically appropriate care for a wide range of issues such as blood transfusions, cardiac catheterizations, cardiac bypass, operations for surgical complication,<ref name="horwitz">{{cite journal | vauthors = Horwitz LI | title = Implications of Including Do-Not-Resuscitate Status in Hospital Mortality Measures | journal = JAMA Internal Medicine | volume = 176 | issue = 1 | pages = 105–6 | date = January 2016 | pmid = 26662729 | doi = 10.1001/jamainternmed.2015.6845 }}</ref> blood cultures, central line placement,<ref name="smith2008">{{cite journal | vauthors = Smith CB, Bunch O'Neill L | title = Do not resuscitate does not mean do not treat: how palliative care and other modalities can help facilitate communication about goals of care in advanced illness | journal = The Mount Sinai Journal of Medicine, New York | volume = 75 | issue = 5 | pages = 460–5 | date = October 2008 | pmid = 18828169 | doi = 10.1002/msj.20076 }}</ref> antibiotics and diagnostic tests.<ref name="yuen">{{cite journal | vauthors = Yuen JK, Reid MC, Fetters MD | title = Hospital do-not-resuscitate orders: why they have failed and how to fix them | journal = Journal of General Internal Medicine | volume = 26 | issue = 7 | pages = 791–7 | date = July 2011 | pmid = 21286839 | pmc = 3138592 | doi = 10.1007/s11606-011-1632-x }}</ref> "Providers intentionally apply DNR orders broadly because they either assume that patients with DNR orders would also prefer to abstain from other life-sustaining treatments or believe that other treatments would not be medically beneficial."<ref name="yuen"/> 60% of surgeons do not offer operations with over 1% mortality to patients with DNRs.<ref name="surgeons">{{cite journal | vauthors = Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ | title = Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey | journal = Critical Care Medicine | volume = 41 | issue = 1 | pages = 1–8 | date = January 2013 | pmid = 23222269 | pmc = 3624612 | doi = 10.1097/CCM.0b013e31826a4650 }}</ref> The failure to offer appropriate care to patients with DNR led to the development of emergency care and treatment plans (ECTPs), such as the [[ReSPECT process|Recommended Summary Plan for Emergency Care and Treatment]] (ReSPECT), which aim to record recommendations concerning DNR alongside recommendations for other treatments in an emergency situation.<ref name="Hawkes 2020">{{cite journal |last1=Hawkes |first1=C |title=Development of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) |journal=Resuscitation |date=2020 |volume=148 |pages=98–107|doi=10.1016/j.resuscitation.2020.01.003 |pmid=31945422 |s2cid=210703171 |url=http://wrap.warwick.ac.uk/131965/1/WRAP-Development-Recommended-Summary-Plan-Emergency-Care-Treatment-%28ReSPECT%29-Hawkes-2020.pdf }}</ref> ECTPs have prompted doctors to contextualize CPR within a broader consideration of treatment options, however ECTPs are most frequently completed for patients at risk of sudden deterioration and the focus tends to be on DNR.<ref name="Eli 2020">{{cite journal |last1=Eli |first1=K |title=Secondary care consultant clinicians' experiences of conducting emergency care and treatment planning conversations in England: an interview-based analysis |journal=BMJ Open |date=2020 |volume=20 |issue=1 |pages=e031633|doi=10.1136/bmjopen-2019-031633 |pmid=31964663 |pmc=7044868 }}</ref>

Patients with DNR therefore die sooner, even from causes unrelated to CPR. A study grouped 26,300 very sick hospital patients in 2006–2010 from the sickest to the healthiest, using a detailed scale from 0 to 44. They compared survival for patients at the same level, with and without DNR orders. In the healthiest group, 69% of those without DNR survived to leave the hospital, while only 7% of equally healthy patients with DNR survived. In the next-healthiest group, 53% of those without DNR survived, and 6% of those with DNR. Among the sickest patients, 6% of those without DNR survived, and none with DNR.<ref name="fendler"/>

Two Dartmouth College doctors note that "In the 1990s&nbsp;... 'resuscitation' increasingly began to appear in the medical literature to describe strategies to treat people with reversible conditions, such as IV fluids for shock from bleeding or infection... the meaning of DNR became ever more confusing to health-care providers."<ref name="malhi">{{Cite news |url=https://thehill.com/opinion/healthcare/442188-the-term-do-not-resuscitate-should-be-laid-to-rest |title=The term 'do not resuscitate' should be laid to rest |last=Malhi |first=Sabrina | name-list-style = vanc |date=2019-05-05 |access-date=2019-05-29 }}</ref> Other researchers confirm this pattern, using "resuscitative efforts" to cover a range of care, from treatment of allergic reaction to surgery for a broken hip.<ref name="marco2018">{{cite journal | vauthors = Marco CA, Mozeleski E, Mann D, Holbrook MB, Serpico MR, Holyoke A, Ginting K, Ahmed A | title = Advance directives in emergency medicine: Patient perspectives and application to clinical scenarios | journal = The American Journal of Emergency Medicine | volume = 36 | issue = 3 | pages = 516–518 | date = March 2018 | pmid = 28784259 | doi = 10.1016/j.ajem.2017.08.002 }}</ref> Hospital doctors do not agree which treatments to withhold from DNR patients, and document decisions in the chart only half the time.<ref name="smith2008"/> A survey with several scenarios found doctors "agreed or strongly agreed to initiate fewer interventions when a DNR order was present.<ref name="smith2008" />

After successful CPR, hospitals often discuss putting the patient on DNR, to avoid another resuscitation. Guidelines generally call for a 72-hour wait to see what the prognosis is,<ref name="prognos">{{cite journal | journal = CPR & ECC Guidelines |url=https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-3-ethical-issues/?strue=1&id=7-1 | title = Resuscitation, Item 7.1, Prognostication  | publisher = The American Heart Association | quote = Part 3: Ethical Issues – ECC Guidelines, Timing of Prognostication in Post–Cardiac Arrest Adults }}</ref> but within 12 hours, US hospitals put up to 58% of survivors on DNR, and at the median hospital, 23% received DNR orders at this early stage, much earlier than the guideline. The hospitals putting fewest patients on DNR had more successful survival rates, which the researchers suggest shows their better care in general.<ref name="fendler"/> When CPR happened outside the hospital, hospitals put up to 80% of survivors on DNR within 24 hours, with an average of 32.5%. The patients who received DNR orders had less treatment, and almost all died in the hospital. The researchers say families need to expect death if they agree to DNR in the hospital.<ref name="richardson2013"/>