Surgical Residents Harbor Unwarranted Assumptions About DNI/DNR Patients

By Anne Harding

August 28, 2019

NEW YORK (Reuters Health) - Many surgical residents assume that patients with a do-not-resuscitate (DNR) or do-not-intubate (DNI) order may prefer less-aggressive care overall, according to new findings.

"It seems like when presented with hypothetical clinical scenarios that residents are making the assumption that a 'do not resuscitate' and 'do not intubate' order is equivalent to a do not treat order," said Dr. Miriam Y. Neufeld of Boston University School of Medicine in Boston, the study's lead author.

"We shouldn't be making that assumption without having a more extensive conversation with patients and families about specific treatment goals," she told Reuters Health by phone.

Studies consistently show that patients with a DNR or DNI status have higher in-hospital and post-discharge mortality than patients with a "full code" status, even after adjusting for clinical factors that could be associated with worse prognosis, Dr. Neufeld and her team reports in Surgery, online August 16.

Clinicians may also withhold or withdraw therapies such as intensive-care unit (ICU) admission, hemodialysis and intravenous fluid when patients have a DNR/DNI.

In the new study, 194 residents completed an online survey that included four vignettes with 10 questions about diagnostic and therapeutic interventions. Surgery residency programs were randomly assigned to receive one of two versions with different code statuses for included patients.

Residents were consistently less likely to opt for life-sustaining procedures in patients if the vignette indicated that they had a DNR/DNI, Dr. Neufeld and her team found, including surgical procedures that would be standard care in operable patients, both on an elective or emergency basis.

For example, in a vignette featuring an 80-year-old woman with Clostridium difficile colitis, only 81.3% said they would start dialysis in the setting of renal failure when the patient's code status was DNR/DNI. When the patient's status was "full code," however, 97.3% indicated they would do so (P=0.001).

"There were some residents who weren't even having a conversation with the patient or the family about particular aggressive therapies based on (DNI/DNR) code status alone," Dr. Neufeld said.

The researcher emphasized that she and her colleagues aren't suggesting that DNR/DNI patients be treated more aggressively, but that decisions about care be made on a case-by-case basis in consultation with patients and families.

"People get very passionate about this issue on both sides. We're not trying to take a side, just raise awareness that this is something that's influencing our decision-making," she said.


Surgery 2019.