Management of Do Not Resuscitate Orders Before Invasive Procedures

Outside of using education to raise awareness, other improvements could utilize informatics solutions, such as developing an alert on opening a patient chart if a DNR status exists (such as a pop-up screen) or adding code status as an item to a preprocedural checklist. Similar to our study, previous studies also have found that a systematic approach with guidelines and templates improved rates of documentation of code status and DNR decisions.^15,16 A large proportion of the LST notes and procedures done on patients with a DNR in our study occurred in the inpatient setting without any involvement of the primary care provider in the discussion. Having an automated way to alert the primary care provider that a new LST note has been completed may be helpful in guiding future care. Future work could identify additional systematic methods to increase acknowledgment of DNR.

Limitations

Our single-center results may not be generalizable. Although the interaction between procedural area and time was tested, it is possible that improvement in DNR acknowledgment was attributable to secular trends and not the intervention. Other limitations included the decreased generalizability of a VA health care initiative and its unique electronic health record, incomplete attendance rates at our educational sessions, and a lack of patient-centered outcomes.

Conclusions

A templated addendum combined with targeted staff education improved the percentage of DNR acknowledgments before nonsurgical invasive procedures, an important step in establishing patient preferences for life-sustaining treatment in procedures with potential complications. Further research is needed to assess whether these improvements also lead to improved patient-centered outcomes.

Acknowledgments

The authors would like to acknowledge the invaluable help of Dr. Kathryn Rice and Dr. Anne Melzer for their guidance in the manuscript revision process