Pediatric Do-Not-Resuscitate Practice Varies From Intent

Larry Hand

August 26, 2013

Pediatric clinicians apply do-not-resuscitate (DNR) orders not only in cases of cardiopulmonary arrest (which was the DNR's original intent) but also as surrogates for broader treatment directives, according to an article published online August 26 in JAMA Pediatrics. The survey results also show that most clinicians think DNR discussions take place later in the treatment course than they should.

Amy Sanderson, MD, from the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Massachusetts, and colleagues conducted a survey of pediatric physicians and nurses at Boston Children's Hospital and the Dana-Farber Children's Hospital Cancer Center in March, April, and May 2010.

Of 266 survey respondents, 107 (40.2%) were physicians and 159 (59.8%) were nurses. Just more than half (52.6%) worked in intensive care units (ICUs), 20.3% worked as cardiac ICU providers, and 27.1% worked as oncology providers. About 43% had been in practice less than 10 years, 32.7% had been in practice for 10 to 20 years, and 24.0% had practiced more than 20 years.

Two thirds of respondents ( 67%) believed a DNR order applied strictly to resuscitation only on cardiopulmonary arrest, whereas about 33% considered DNR a threshold for limiting treatments not specific to cardiopulmonary resuscitation, with no significant differences seen among nurses and physicians or among specialties.

However, 69% of respondents reported that care of a patient with a life-threatening illness changed once a DNR order is in place (95% confidence interval [CI], 62.7% - 74.1%), with physicians being more likely to believe this (χ2 = 11.15; P = .004) than nurses. Slightly more than half (52.1%) of the participants report that changes in care go beyond nonresuscitation and an emphasis on comfort to limiting or withdrawal of diagnostic and therapeutic interventions.

Despite the changes in care, almost all (97.1%) respondents believed they were not "giving up" on patients with DNR orders.

Of 224 respondents who indicated specifically when DNR discussions should take place, 178 (79.5%; 95% CI, 73.7% - 84.2%) reported that these "discussions should first be initiated either on presentation (n = 99) or during a period of stability (n = 79) rather than during an acute illness (n = 39) or when death is clearly imminent (n = 7)," the authors write. "However, of the 229 respondents who indicated a specific answer regarding when these discussions typically occur, 211 (92.1%; 95% CI, 87.9%-95.0%) reported that, in actuality, the discussions take place during an acute illness (n = 80) or when death is clearly imminent (n = 131). Clearly, there is a difference in perspective between when clinicians believe initial DNR discussions should take place and when they actually take place (χ2 = 256.41, P < .001)."

The biggest barriers to DNR discussions were unrealistic parent expectations (39.1%), lack of parent readiness to have the discussion (38.8%), and differences between clinician and patient/parent understanding of the prognosis (30.4%).

Limitations of the study include a possible lack of generalizability resulting from the survey being limited to the 2 locations.

In an accompanying editorial, John D. Lantos, MD, from the Children's Mercy Bioethics Center, University of Missouri at Kansas City, writes that the difference in original intent of DNR orders and the everyday clinical practice may be a result of lack of training for clinicians or clinicians' lack of belief in conventional wisdom about DNR orders.

Dr. Lantos writes, "The data suggest that experienced clinicians have some degree of cognitive dissonance regarding current bioethical paradigms. They think one thing but do another. We should at least be open to the possibility that practitioners have experiential wisdom that preachers of theory lack."

The authors and the editorialist have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online August 26, 2013. Abstract


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.