Physicians' experiences with prehospital do-not-resuscitate orders in North Carolina

Abstract

Introduction: Many states are implementing prehospital do-not-resuscitate (DNR) programs through legislation or by state or local protocol. There are no outcome studies in the literature regarding the utilization of, access to, or barriers to prehospital DNR programs, nor are there studies that evaluated whether they meet the patients' needs.

Study objective: To explore physicians' perceptions of the utilization of, access to, and barriers to a southeastern state's prehospital DNR program, and to identify key professional groups needing information about prehospital DNR issues.

Methods: A convenience sample survey and a descriptive review using retrospective, self-report questionnaires sent to all physicians who requested and obtained a supply of the state's out-of-facility DNR forms in 1993.

Results: Respondents reported that the most common terminal conditions for patients with prehospital DNR orders are cancer and multiple chronic diseases in elderly patients. More than half of the physicians recalled that enrolled patients had engaged the services of emergency medical services (EMS), most often because the patients' conditions worsened, and the families were uncertain about what to do. Most of the enrolled patients have at least one other DNR order in another health-care setting, and are at home with hospice care or home-health care at the time of the prehospital DNR order implementation. The most frequent barrier to honoring dying patients' wishes in the prehospital environment is a lack of knowledge of prehospital issues by patients, families, primary care physicians, and nursing home staff. Ninety-eight percent of the respondents support a single, universal DNR order that would apply across all health-care settings.

Conclusions: Patients, families, and key health-care professional groups need to be targeted with educational programs regarding prehospital DNR issues. Primary care physicians, using the current prehospital DNR program, support more comprehensive approaches to DNR orders across health-care settings.