New research presented at this year’s ESICM LIVES conference shows that where ‘do not resuscitate orders’ (DNR) are used at the end of life, putting them in place before the patient enters intensive care (ICU) or in the first 2 days of their ICU stay makes them far less likely to have a poor quality of death.

In this study, Dr Lindsay Lief, Weill-Cornell Medicine, Center for Research on End-of-Life Care, New York, NY, USA and colleagues aimed to determine the relationship between the timing of a DNR order, and patients’ perceived suffering, peacefulness and quality of death.
200 ICU patients at New York Presbyterian Hospital in New York and Brigham and Women’s Hospital in Boston were assessed by the ICU nurses (n=100) who cared for them during their last week of life. Trained research staff interviewed the ICU nurses about their perceptions of the patients’ experience using validated measures to assess the patients´ quality of death, extent of peacefulness, and suffering. Data was taken from charts to assess the timing of DNR orders in the patients´ terminal ICU stay.

The data showed that 77.5% (155/200) of enrolled patients had a DNR order at the time of death. These included 18% (36/200) of patients that were admitted to the ICU with a pre-existing DNR order (included in the early DNR group), and 59.5% (119/200) had a DNR order placed during their ICU stay. It was found that 13% (26/200) of patients had a DNR placed within 48 hours of ICU admission (also included in early DNR group) and 46.5% (93/200) had DNR orders placed after 48 hours of ICU admission (late DNR group). Close to half of patients in the study (42.5% [85/119]) had a DNR order placed within 48 hours of their death.

Compared to those without a DNR order, patients with an early DNR order were much less likely to have a poor quality of death (27.6% vs. 54.5%;) and more likely to be “at peace” at the time of their death (56.0% vs. 38.8%;). Further analysis indicated that those with late DNR were significantly more likely than those with early DNR to experience suffering in their last week of life (48.4% vs. 30.5%)

The authors conclude: “At the time of death in the ICU, many patients have DNR orders in place, though most of these were placed after admission to the ICU and many in the last 1 to 2 days of life. Placement of a DNR order prior to ICU admission and earlier in the terminal ICU stay is associated with an improved quality of death. Ensuring earlier conversations about DNR among patients dying in the ICU may improve patients’ quality of death and reduce suffering at the end of life.”