A patient's choice of do-not-resuscitate (DNR) status is a major one, and communicating this status in the hospital is often the responsibility of nurses. The American Nurses Association position statement, Nursing Care and Do Not Resuscitate and Allow Natural Death Decisions, states that nurses have a duty to “communicate known information… to appropriate health care personnel” and to “advocate for a patient's end-of-life preferences.”
While accrediting organizations require hospitals to document patients’ end-of-life preferences at admission, many health care institutions limit documentation of a patient's code status to paper and electronic charting, leaving communication gaps that can lead to wrongful resuscitations and mistaken fatalities. Not having a code status identifier on or near the patient is unsafe—patients don't always code on their own unit, where nurses know their directives. The patient's advance directives, if unknown during a code, would have to be looked up in the paper chart or the electronic health record (EHR), either of which takes time.
Practices are changing, but a 2007 study by Sehgal and Wachter found that over half (56%) of respondents’ institutions used only paper documentation for patients with a DNR order and 16% used EHRs. About 25% reported using color-coded wristbands in addition to either paper or EHRs. More than 70% of respondents were aware of a case at their institution in which “confusion around a DNR order led to problems in patient care.”
Color-coded wristbands communicate readily recognizable information about patient conditions and wishes. Various colors are used to indicate fall risk, bleeding risk, allergy alert, limb restriction, and more. Many hospitals now use wristbands as a way to identify a patient's status during a code, and nationwide initiatives have been implemented to make certain that wristband colors are standardized to limit confusion. In 2007, the Greater New York Hospital Association found that 69% of their organizations were using color-coded wristbands for patients and residents with DNR orders; however, these wristbands did not always follow a standardized color scheme. The voluntary initiative they developed, Colors of Safety Across the Continuum of Care, joined the national effort to enhance patient safety by adopting the standardized wristband colors for DNR (purple), falls (yellow), and allergy risks (red). An increasing numbers of states have adopted similar color standardization.
Joint Commission recommendations for DNR wristbands include having brief preprinted text on the wristbands to reduce the chance of error, particularly for color-blind staff. DNR wristbands are only appropriate for patients who want no resuscitative measures. For patients who want limited resuscitation (such as intubation or pressors), staff should continue to use electronic and/or paper charting, since the wristband in this case may cause more confusion than clarity. Wristbands do not replace electronic or paper-based advance directive documentation, but are to be used as a supplementary reminder. Staff should always fully explain the use of the DNR wristband and remind patients that it is optional.
A common objection to DNR wristbands is that they are a potential violation of the patient's confidentiality. While this concern is understandable, the Joint Commission does not regard the standardization of color-coded wristbands as a privacy violation. Moreover, hospitals that have instituted use of the purple DNR wristband have reported that patients feel safer and are satisfied with its use.
Another concern about color-coded wristbands is that those patients labeled as DNR may receive care of lesser quality. One way to address this concern is to promote greater communication between patients and their nurses and physicians about all aspects of the patient's plan of care.