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Original Research: Nurses' Perspectives on Caring for Patients with Do-Not-Resuscitate Orders

Kelly, Patricia A. DNP, APRN, AGN-BC, AOCN; Baker, Kathy A. PhD, APRN, ACNS-BC, FCNS, FAAN; Hodges, Karen M. BSN, RN, OCN; Vuong, Ellen Y. MSN, RN; Lee, Joyce C. MSN, RN, NEA-BC, OCN; Lockwood, Suzy W. PhD, RN, OCN, FAAN

Author Information
AJN, American Journal of Nursing: January 2021 - Volume 121 - Issue 1 - p 26-36
doi: 10.1097/01.NAJ.0000731652.86224.11
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At first glance, a do-not-resuscitate (DNR) order might seem clear enough, its implications plain. But consider the following situations:

  • A nurse calls in a report to the ICU for a patient on another unit who has a DNR order. The receiving nurse responds, “Why is he coming here? He's DNR.”
  • Family members revoke a DNR order because they believe their loved one's DNR status has caused her to receive suboptimal care.
  • When asked what a DNR order means, a nurse says, “I interpret it to mean that the patient doesn't want lifesaving interventions. But my interpretation will also depend on the clinical presentation of the patient.”

Such confusion about what a DNR order means, with some interpreting it to mean “do not treat” or associating it with less or suboptimal care, has been extensively documented in the medical literature.1-6 Yet the clinical impact of DNR orders, particularly with regard to nursing care, has not been well studied.

Study purpose. The purpose of this study was to explore direct care nurses' perspectives on the meaning and interpretation of DNR orders in relation to caring for hospitalized adults with such orders in the United States.

BACKGROUND

DNR orders for hospitalized patients have been used for more than 40 years, in response to problems reported with the cardiopulmonary resuscitation (CPR) of terminally ill patients.7 The American Medical Association (AMA) published resuscitation guidelines in 1987 and updated them in 1991.8 But these guidelines discussed DNR in terms of CPR, without delving into the clinical implications of DNR orders. Since that update, several studies have investigated the impact of DNR orders on mortality,2, 5, 9 quality assurance measures,10, 11 ICU admissions,12 and physician decision-making.6

Recognizing the potential for DNR misinterpretations among nurses, the American Nurses Association (ANA) issued a position statement in 2003; the most recent update was published in 2020.13 The current statement, Nursing Care and Do-Not-Resuscitate (DNR) Decisions, acknowledges that “both health care providers and the public can be confused” about the meaning and implications of DNR. The ANA statement further says, “Patients with do-not-resuscitate orders must not be abandoned, nor should these orders lead to any diminishment in quality of care.” (Further complicating the picture is the proliferation of alternative terms; for more, see DNR Terminology.3, 9, 14-17)

Box 1
Box 1:
DNR Terminology

In reviewing the nursing literature with regard to DNR, we found that much of it is dated18-21; focuses on pediatric populations22, 23; or reflects the perspective of nurses in countries such as Iran,24, 25 Jordan,26 Sweden,27 and the United Kingdom,28, 29 where legislation and cultural norms differ from those in the United States.

METHODS

Study design and setting. This was a mixed-methods descriptive study. It involved both an online survey inviting multiple-choice and free-text responses to a DNR case study and confidential one-on-one interviews, conducted in person or by telephone, about DNR perspectives. To establish qualitative rigor, the study protocol incorporated elements to ensure the findings' credibility, applicability, and consistency, as described by Sandelowski.30

The study site was an 875-bed urban hospital in the southwestern United States. The hospital system's institutional review board approved the study before data collection began.

Research team. The research team included four nurses (PAK, KMH, EYV, and JCL) practicing in the hospital where the study was conducted, which afforded the team context and site familiarity. Two additional nurse researchers (KAB and SWL) who are experts in qualitative methods and worked outside the study setting also participated.

Sample. A purposive sampling technique was used. Direct care nurses from three adult inpatient care units at the study site were invited to participate. We selected the units because these nurses frequently care for patients with DNR orders. Sample inclusion criteria were being a direct care RN employed full or part time and working on one of the three units: a 23-bed oncology unit, a 23-bed medical–surgical unit, and a 35-bed progressive cardiac step-down unit.

With permission from the nurse managers, investigators first introduced the study at unit meetings and posted copies of the invitation letter on unit bulletin boards. The invitation letter, which contained a link to the confidential online survey on the Qualtrics survey platform, was then e-mailed to all full- and part-time nurses on the three units. Both the e-mail letter and the survey website included information about the study purpose, eligibility, risks, benefits, expected lengths of time for taking the survey and participating in the interview, and the option to withdraw at any time, as well as contact information if any questions arose. Consent information and the option to consent or decline were incorporated into the survey itself.

Consented participants first read the case study and answered the survey question online. Demographic data were also collected with the survey. Participants were then asked whether they wanted to be contacted about participating in a confidential interview. Those who selected “yes” were directed to a new screen, where they were asked to provide their contact information and preferred method of contact. The nurse researcher who would be conducting the interviews (KAB) texted or called potential participants to schedule these interviews.

Tools and data collection. The principal investigator (KMH) developed two DNR case studies using deidentified patient cases. The research team reviewed these case studies for content validity, then selected one and piloted it (see Case Study with Directions for Participants) with two direct care nurses. No changes were made as a result of the pilot. The team then created a semistructured interview guide for use in the interviews. This was designed to elicit more information about the experiences of nurses caring for patients with DNR orders.

Box 2
Box 2:
Case Study with Directions for Participants

The case study and survey were posted online from May through October 2018. All interviews took place between June and November 2018. To protect their confidentiality, interviewees were identified only by their assigned unit and years of nursing experience. All interviews were audiotaped and transcribed by a professional transcription service familiar with research protocols. Interview duration ranged from 12 to 39 minutes, with an average of 25 minutes. The interviewer (KAB) is skilled in qualitative interview methods, is not employed by the hospital, and did not have a working relationship with the participants. Nurses participating in the interviews did so on their own time and were not compensated by the hospital.

The interviewer used the semistructured interview guide in conducting each interview. The script incorporated the following open-ended questions:

  • When you see an order for a DNR, what does that mean to you?
  • Do you have any DNR experiences that come to mind, whether these were positive experiences or stressful negative experiences?
  • Does a DNR order influence the way other nurses respond to the care of patients?
  • Have you had formal training in palliative or hospice care?

Additional probing questions were asked when needed to delve deeper into the participants' experiences (for example, “Tell me more about that,” “Explain that to me,” “How did your colleagues respond to that?,” “Is there anything else you'd like to tell me about your experiences caring for patients who have a DNR order?”). Interviews were conducted until it was determined that no new information was being gleaned, an indication of data saturation.31

Data analysis. Descriptive statistics were used to report responses to the DNR case study and participant demographic data. Thematic analysis methods guided analysis of qualitative data.32 Given our focus on understanding nurses' experiences, these methods also have phenomenological (lived experience) overtones. The nurse researcher who conducted the interviews reviewed the typed transcriptions against the audiotapes to ensure transcription accuracy. The interviewed participants were also asked to review the transcripts and provide feedback, corrections, or additions. Research team members first reviewed the interview transcripts separately, and then did so as a team using iterative and reflective processes. Questions from the semistructured interview guide were used as an organizing framework. Each team member individually coded the transcripts for initial keywords and phrases (such as “comfort care,” “no aggressive measures”) and subsequent categories (such as DNR meaning, points of confusion). After multiple readings and familiarization with the transcripts, the team reached consensus on the salient theme and subthemes.

FINDINGS

Sample. Of the 37 nurses completing the online survey's demographic data section, 35 also answered the case study question. (We report demographics for all 37 nurses because we were unable to determine which two nurses didn't complete the case study portion.) The overall survey response rate was 47%. Of the nurses who completed the demographic data, 14 were from the medical–surgical unit, 13 were from the oncology unit, and 10 were from the progressive cardiac step-down unit. Participants were diverse in age, race and ethnicity, years of practice, and highest educational degree (see Table 1). Because there were few male nurses on the study units, we decided not to include gender in order to minimize the potential for loss of confidentiality.

Table 1. - Demographics of DNR Case Study Participants (N = 37)a
Variable n (%)
Age, years
   20-29 11 (29.7)
   30-39 12 (32.4)
   40-49    7 (18.9)
   50-59    4 (10.8)
   ≥ 60    3 (8.1)
Race/ethnicity
   American Indian/Alaska Native    0 (0)
   Asian    8 (21.6)
   Black or African American    7 (18.9)
   Hispanic or Latino    6 (16.2)
   Native Hawaiian or other Pacific Islander    0 (0)
   White 13 (35.1)
   Prefer not to respond    3 (8.1)
Highest nursing degree
   Diploma    1 (2.7)
   Associate degree    2 (5.4)
   BSN 32 (86.5)
   MSN    2 (5.4)
Nursing experience, years
   < 2    6 (16.2)
   2-5 12 (32.4)
   6-10    5 (13.5)
   > 10 14 (37.8)
DNR = do not resuscitate.
aDemographics are reported for all 37 nurses because we were unable to determine which two nurses didn't complete the case study portion.Note: Percentages may not sum to 100% because of rounding.

Of the 35 nurses who completed the DNR case study survey, 15 indicated interest in participating in an interview, and 13 scheduled interviews and completed the interview process. Twelve of the interviews were done by telephone and one was conducted in person in a private conference room at the hospital. Interview participants reported having between one and 41 years of nursing experience (mean, 14 years). Six participants worked on the oncology unit and seven worked on the progressive cardiac step-down unit.

Case study. Thirty-five participants read the case study and answered the multiple-choice question, choosing one from four possible answers. Of these participants, 28 (80%) elaborated on their choices, in accordance with the “Explain your response” instruction.

Twenty-one of the 35 participants (60%) chose option c, “The patient's code status indicates palliative care as the priority.” Explanatory comments focused on the importance of symptom management, including pain control. One participant wrote,

“A DNR would mean simply that we do not “code” the patient if they were to lose pulse or stop breathing. In this case, it appears we are still treating the patient, assessing the caloric needs, treating the pain. I think a palliative consult would be good, to assess the priorities of the patient and to determine the right course of action to alleviate suffering.”

But another participant shared a different perspective: “The patient appears to no longer want to continue treatment. It would be a priority for the patient to initiate palliative/hospice.”

Ten participants (28.6%) chose option d, “Other.” Explanatory comments included the following:

“There is not enough information here to decide the level of care this patient desires/needs, apart from the directive to not resuscitate.”

“DNR does not necessarily mean they do not want treatment or are ready for end of life. A palliative care consult needs to be placed before taking palliative care as a priority. A meeting needs to be done with the patient and family regarding what they want.”

Four participants (11.4%) chose either option a, “The patient's code status indicates end-of-life care as the priority,” or option b, “The patient's code status indicates no desire for treatment as the priority.” One participant commented, “This patient doesn't want any invasive treatment for continuity of life. Intravenous placement inflicts more pain on the patient.”

For more on participants' responses to the case study, see Figure 1.

Figure 1.
Figure 1.:
Case Study Participant Responses (N = 35)a

Interviews. From the 13 interviews, the research team identified one overarching theme and three subthemes.

Overarching theme: Varying interpretations of DNR orders among nurses were common, resulting in unintended consequences. Perceived variances among other health care team members, patients, and families were also reported. The lack of clarity and agreement about what DNR means in practice has a far-reaching impact for all involved. Numerous unintended consequences can include shifts in care, varying responses to deteriorating status, tension, and differences in role expectations. Specific examples of such consequences are given with the subthemes below.

Subtheme 1: Nurses gave clear definitions of DNR, but they described ambiguity and varying responses when interpreting DNR orders in clinical practice. The interviewed participants gave similar answers to the question “When you see an order for a DNR, what does that mean to you?” Seven participants defined DNR as “no resuscitation,” and six elaborated with comments such as “no compressions or ventilations” or “no resuscitation but treat all other needs.” Several participants said that patients in similar circumstances should receive the same care regardless of their DNR status, describing the need to treat patients' distress.

But participants had varying opinions concerning the specifics of caring for a patient with a DNR order. One participant said that if the patient were unresponsive,

“we would not do chest compression or try and shock the patient or do anything. We would let them be at peace. . . . In terms of care, they're going to receive the exact same care that anybody else would receive on the unit. . . . So, if they go in respiratory distress, I would definitely call a rapid response [team] in and make sure we get them to where they're back comfortable and can breathe okay.”

“Another said,”

“I interpret it as obviously they don't want chest compressions and intubation, [or] any of the lifesaving interventions that if the patient were to go into cardiac arrest, we would do. But I will say the way that I do interpret it also kind of depends on the clinical presentation of the patient.”

Two participants stated that DNR orders meant no aggressive measures in lifesaving interventions. But this interpretation led to some confusion about the code status regarding calling a rapid response team (RRT). As one said,

“It's the same as a full code unless I know they're not doing well . . . and that's the other thing, too, is I want to call RRT. But then I'm like “Do I really need to call for her?””

Several participants expressed uncertainty about whether to intervene with aggressive measures if there was a change in the patient's condition. One participant avoided such confusion by verifying the patient's DNR status with the patient at handoffs: “‘You are DNR, is that correct?’ and they'll be like, ‘Yep, you're not going to do anything to me,’ and I'll respect their wishes.”

One participant described DNR in terms of palliative end-of-life care measures: “No CPR, first off, and then no aggressive measures, perhaps. That would be in the back of my mind, and if I need to discuss palliative care with the physician.” Another participant reported being “hyperconscious” when caring for a patient with a DNR order: “Knowing that I won't be doing CPR, if they digress [decline] how can I either A, prevent it, or B, know what would I do next?”

And one participant shared this account: a patient with a DNR order came in for a cardiac procedure and became hypotensive. The patient's primary nurse didn't intervene early, interpreting the DNR order as “do not treat.” The incoming nurse recognized the situation as a failure to save. The patient was moved to a higher level of care but was unresponsive, and the family decided to place the patient on hospice care.

Subtheme 2: Nurses identified situations in which health care team members did not agree on the clinical implications of and team member responsibilities for DNR orders. The interviewed participants described differing role expectations and views about the implications of a DNR order among team members. Some reported using these opportunities to advocate for nursing and patients.

One participant described how a physician's expectations about the nurses' role differed from her own, recounting an experience she had while entering a code status in a patient's electronic health record.

“[The physician] says, “What does the patient want?” And I'm like, “Well, that's not for me to decide. That's for you to come and talk with them about . . . because that's not within my scope.””

Another participant described a situation where a patient with a DNR order was going “downhill,” but was still awake and alert. The nurse called the physician, who ordered a morphine drip. The nurse felt strongly that the patient should be informed about what to expect and should be included in this treatment decision. She saw this as part of the physician's role, telling him,

““You need to come and talk to her. Her respirations and oxygen saturation are low, but it's not like she's not alert or doesn't need to be talked to about how ‘We're going to kind of let you go now.’””

This subtheme was further illustrated by situations involving decisions about calling an RRT. One participant stated,

“It's kind of fifty-fifty. [Some]times when we call a rapid response or something on a [patient with a] DNR, and people get there like, “It's a DNR. What do we do?” And it's like, “But you can still do things.” And I do charge, so I find I'm often the one calling it, and the one to make the decisions. . . . A lot of times, it's like nurse[s] are trying to advocate for the patient in matters for DNR. But it's other providers as well, NPs and PAs and physicians. . . . Depending on the [provider] you're going to get a different kind of response [to an RRT].”

During the interviews, participants also suggested that different interpretations of DNR orders could influence how patients were viewed. For instance, one participant said, regarding addressing a change in status, “It's okay because they're DNR.” Another said, “I just think that there can be a stigma on being a patient with a DNR wristband or a DNR order.” Yet other participants spoke of advocating firmly on behalf of patients with DNR orders. As one said, “If there are certain symptoms that you can relieve them of, it should be a priority.” Another participant commented, “I tell them [other nurses], ‘That patient needs to be taken care of.’ If he has to go to ICU, we need to send him.”

One participant described a situation that taught the unit nurses the importance of not stopping all treatment just because a patient has a DNR order. When this patient experienced respiratory distress, he was placed on continuous positive airway pressure and taken to the ICU. The participant noted, “When he came back to the floor, he was walking and talking.” Another participant shared her frustration with varying interpretations of a DNR designation:

“Being a DNR doesn't mean you're a hospice patient. It doesn't mean that you're not going to do everything that you would for anybody else. It's just their directive not to do one thing, and that is CPR.”

Another participant spoke of defining DNR in terms of levels of care and the use of limited codes in order to prevent confusion among team members. She had experienced this approach in a previous employment setting, and felt it was beneficial. Two participants said that designating DNR care levels provided clarity for the nurse and others on the health care team, giving them a more specific sense of a patient's wishes. As one noted,

“[For instance] you've got DNR/COT, which is Continue Other Treatment, which is like being a regular patient. But if their heart stops, then it's just too bad. Or they're DNR/AND, which is Allow Natural Death, so that if they are on hospice, you put them on that. So we know: don't give them regular meds. Don't give them supplemental oxygen. . . . Limited code is pretty much if you don't want to be compressed or intubated, but you do want to get epi[nephrine] and defib[rillation].”

On the other hand, sometimes confusion arose because a DNR order was lacking. Several participants described situations in which the patient's clinical presentation clearly indicated that resuscitation would not be of benefit, yet no DNR order was in place. In other instances, a patient who'd had a DNR order on previous admissions was readmitted, but the DNR order was not reinstated.

Subtheme 3: Family members could be conflicted and confused about DNR orders and a patient's changing status. Participants referenced situations in which patients and family members disagreed about a DNR designation or family dynamics complicated decision-making. One participant said,

“Most of the time, it's really that the family [members] don't understand where the doctors are going with his treatment. . . . Sometimes after they have that [case conference], then the family will understand that we're all trying to get the patient comfortable with or without treatments. . . . Sometimes the family [members] don't understand what's going on. They're fighting because [they think] maybe we are withholding treatment.”

Another participant recounted the case of a patient whose family members didn't understand what it meant for their loved one to have a DNR and be on comfort measures.

“His family had just made him DNR. And because he was DNR, they felt they could give him whatever they wanted to give him, like food and drink even though he was aspirating. . . . I felt it had to do more with the family's idea of what a DNR means, I guess. They were like, “Well, now we just do all kinds of comfort.” And we're like, “Yeah. But doing everything like you would if he was normally okay is not really for his comfort.””

Some participants reported that seeing a loved one with a DNR armband was at times difficult for family members. Comments included, “But [as] family, they just can't let go, I guess,” and, “They see health care workers as miracle workers.”

Participants also noted that family members could become conflicted or confused when the patient's condition changed. In one case, the patient had signed a DNR order, then subsequently went into asystole. The family, which was in the room, revoked the patient's DNR order.

Lastly, participants indicated that case conferences were helpful for both the family and the health care team, allowing them to talk together about what is achievable. One participant said,

“Most of the time, it's really that the family don't understand where the doctors are going with treatment . . . it's a lot of confusion. . . . So they'll have a meeting and talk about “Okay, what is the goal for this patient? What can we achieve?” . . . Then the family will understand that we're all trying to get the patient comfortable with or without treatments.”

DISCUSSION

DNR interpretation. DNR is a widely recognized medical abbreviation. Yet, as our findings show, interpretations of the term vary widely. The AMA's definition of DNR, which can be given succinctly as “do not do CPR,” has been in place since 1987.8 More recently, the medical literature has revealed a broader range of explanations for the term, and too often it's interpreted to mean “do not provide additional lifesaving care,” resulting in reports of biased medical management and care limitations.3, 12, 33

In this study, we found a similar broadening of the DNR definition from nurses' perspectives. When survey participants were asked to respond to the case study by choosing care priorities based on DNR status, more than half (60%) chose palliative care. Multiple-choice questions can be difficult, and it's common for individuals to read information into a scenario. Several participants recognized that they weren't given enough information to determine the patient's wishes and needs regarding further treatments. Still, it's significant that in this survey, the majority of participants associated DNR status with palliative care.

The interviewed participants also provided a range of DNR interpretations. Many participants correctly defined DNR, while others extended the definition by adding qualifiers according to a patient's clinical presentation. The interpretation of a DNR order to mean palliative, end-of-life, or “comfort” care is not new. In 1994, Henneman and colleagues conducted a quasi-experimental study involving clinical nurses' responses to two case scenarios describing critically ill patients.18 The scenarios were identical except that one included a sentence noting that the patient had a DNR order. Respondents indicated that they were less likely to provide physiological monitoring or aggressive interventions for the patient with the DNR order, although they were more likely to provide psychosocial care.

While our study primarily addressed nurses' interpretations of a DNR order, several participants shared situations in which family members didn't understand the meaning of the DNR order or the plan of care. These findings are supported in the literature.27, 34 A concerning finding from our interviews is that family members can misconstrue a DNR order to mean that the health care team has given up on the patient. This finding too is supported in the literature.14, 35

Unintended consequences. Shifts in care. Unintended consequences occur when there is a misalignment of DNR interpretations among health care team members, patients, and family members. National organizations have addressed such potential unintended consequences. For example, The Joint CommissionComprehensive Accreditation and Certification Manual includes an element-of-performance standard that addresses patient care, treatment, and end-of-life services: “The existence or lack of an advance directive does not determine the patient's right to access care, treatment, and services.”16

Several participants were adamant that a DNR order did not change their nursing care, yet also reported that DNR orders changed the care given by other nurses. These findings are consistent with those of Sanderson and colleagues, who surveyed 159 nurses and 107 physicians regarding DNR orders in a pediatric population.23 The researchers found that 69% of those who responded believed that patient care changes once a DNR order is initiated. More than half reported that such care changes included the limitation or withdrawal of diagnostic and therapeutic interventions aside from offering comfort care. These findings were more likely for physicians and oncology specialists than for nurses and other specialists.

In our study, some participants used descriptive terminology to explain such shifts in care. As one said, with a DNR order “[it's] kind of like that person is put on the back burner.” Bardach and colleagues reported similar findings when they surveyed 72 health care providers, including 48 nurses, about their understanding of DNR orders.14 Responses indicated shifts in care, with one nurse interpreting DNR to mean “don't do anything other than basic or palliative care.” In our study, shifts in care were also reported as delays in care.

Varying responses to deteriorating status. Several participants reported that for patients with DNR orders who began to deteriorate, decisions to call an RRT and subsequent responses by RRT members were problematic. Similar dilemmas were reported in the study by Bardach and colleagues, with respondents indicating that “other clinicians” often did not have clear interpretations of DNR orders.14 For example, one nurse said, “I called rapid [response] on a DNR patient and the rapid response team was more concerned about DNR status than helping the patient.” Our study participants reported similar issues when a patient with a DNR order was transferred to the ICU.

Tension. Participants reported that varying interpretations and responses to DNR orders were stressful for them and other team members. One participant described herself as being in a constant state of readiness when caring for deteriorating patients with DNR orders. That stress increased when an RRT was called and when RRT members disagreed about the patient's care or transfer to the ICU. Participants also reported concern when other providers neglected a patient with a DNR order because they interpreted it to mean “do not treat.” Particularly stressful were situations in which there was a discrepancy between a patient's DNR status and what the nurse understood to be the patient's wishes.

Differences in role expectations. Participants spoke of differences in role expectations between physicians and nurses about DNR orders and plan of care communications. Several participants shared instances when they perceived pushback from hospital staff in talking about DNR with patients and family members and advocated increased communication between physicians and patients and family members. Similarly, in the study by Bardach and colleagues, clinicians reported problems with the timing and quality of code status discussions that in part stemmed from differences in role expectations.14 As one respondent said, “No one is addressing [code status] . . . until it has to be addressed.” They further indicated that patients' wishes weren't always followed. Yuen and colleagues have suggested that physicians are inadequately prepared to discuss resuscitation preferences and the care ramifications with patients and family members.36 They point out that physicians in training have reported learning about DNR communication by informally observing other physicians, perhaps perpetuating long-standing misconceptions about DNR orders.36

Nursing implications. Practice. It's critical for nurses to understand that DNR orders do not substitute for plans of care. The plan of care for a patient with a DNR order should reflect a multidisciplinary approach, with defined treatment objectives that honor the patient's and family's wishes and values. Numerous experts support this. Moffat and colleagues write that resuscitation decisions should be “contextualised within overall goals of care”29; and Burns and Truog state that a DNR order should be considered “only a footnote to the overall plan.”7 Sanders and colleagues put it succinctly: “Nothing can be assumed about a patient's plan of care from a DNR order only.”37 The plan of care for a patient with a DNR order may or may not include a referral to palliative care. Regardless, the health care team must understand that a DNR order does not mean palliative care. In our study, interviewed participants stated that case conferences were helpful for both the health care team and the patient's family. The care coordination role is a well-established competency for all RNs,38 and thus RNs can and should take the lead in organizing team conferences and initiating the plan of care.

Education. It's vital that all team members know how to properly interpret a DNR order, understanding what it does and doesn't mean. But it can be difficult to overcome misconceptions that have been in place for decades. In a systematic review of interventions to improve the appropriate use of and outcomes associated with DNR decisions, Field and colleagues found that clinician education in isolation was of limited benefit.39 The most promising interventions were multimodal, combining self-reflection with case-based discussions and role play. We recommend a similar multimodal approach that incorporates interdisciplinary reviews of hospital-based cases of patients with DNR orders, similar to the scenario in our survey. Using real-life cases would allow team members to address DNR issues within the culture and context of their work environment. We also encourage the use of self-reflection exercises and journaling to address team members' beliefs about resuscitation, end-of-life issues, and the impact of age and health status on the perceived value of a life. Many participants shared that DNR education occurred primarily “on the job,” underscoring the need for competent nurse mentors and preceptors.

Although a patient with a DNR order may or may not be in palliative care, it's important for providers to understand palliative care and end-of-life issues. When asked whether they'd attended any continuing education programs in recent years that covered palliative care as a primary topic, none of the interviewed participants said they had. One participant reported that palliative care was addressed at an in-service training, and two reported having had some palliative care content in nursing school. Palliative care services focus on improved quality of life and offer a support system for patients and family members facing life-threatening illnesses.40 According to a systematic review by Chen and Hsiao, a palliative care approach provides a shared decision-making model that can result in earlier patient and family decisions about DNR orders and improved DNR designation rates.41

In listing objectives for baccalaureate-prepared nurses, the American Association of Colleges of Nursing states that the nurse should be prepared to “implement patient and family care around resolution of end-of-life and palliative care issues”42; but specific education regarding DNR orders isn't addressed. In the study by Sanderson and colleagues, most nurses reported receiving little or no structured (92%) or bedside (91%) training in resuscitation discussions during nursing school, and little or no structured (53%) or bedside (41%) training in such discussions after completing school and postgraduate job training.23 We strongly recommend adding DNR-related education to prelicensure curricula. In the hospital setting, preceptors for newly hired nurses should receive education on DNR orders and how these may or may not affect plans of care.

Advocacy and policy. Given their close relationships with patients and family members, nurses have an important role to play in DNR discussions and decision-making. Indeed, nurses are often the advocates who ensure that DNR orders are in place35 and that an appropriate plan of care has been established. The ANA's Code of Ethics for Nurses with Interpretive Statements notes that while nurses may not agree with patient decisions, they are advocates for patients' right to self-determination.43

Per the Joint Commission, every hospital should have written resuscitation policies in place.16 Nurses have a leading role to play in developing, implementing, and revising hospital policies,43 including those related to resuscitation. Yuen and colleagues have proposed that resuscitation policies address the identification of patients for whom DNR discussions are appropriate, the leadership responsible for these discussions, and the information to be provided for timely decision-making by patients and families.36 Nurses should be aware of relevant legislation in their state of practice, as specifics vary from state to state.

Research. Further research investigating nurses' perspectives about the meaning and interpretation of DNR orders is warranted. Suggested areas for research include exploring the impact of DNR perceptions on quality assurance measures, such as RRTs, ICU admissions, and palliative care referrals. Interprofessional research teams should also investigate the impact of DNR orders on collaborative decision-making among health care team members, patients, and families.

For a concise list of these implications, see Recommendations Regarding DNR Orders.13, 43

Box 3
Box 3:
Recommendations Regarding DNR Orders

Limitations. This study was conducted on three specialty units (oncology, medical–surgical acute care, and progressive cardiac care) at a single urban hospital, limiting the generalizability of the findings. Future studies should involve multiple sites in various geographic locations. The sample size was small, and participants were self-selected and not randomized. Thus, the sample may not fully reflect nurses' experience with DNR orders, and nurses with a strong interest in the topic may have been overrepresented. The online survey asked participants to respond to a single de-identified case study; we did not observe nurses' actions in clinical settings. In the interviews, participants self-reported their experiences and thoughts, which could have been subject to recall bias.

CONCLUSIONS

While the definition of DNR might seem straightforward, its interpretation in clinical practice can be complicated. In this study, most of the nurses understood the meaning of DNR. Yet their interpretations often indicated clinical situations in which a DNR order was misaligned with the plan of care or was misinterpreted as replacing it. In every setting, nurses have opportunities to clarify such misinterpretations through practice, education, advocacy and policy, and research. After 40 years as one of the most widely recognized medical abbreviations, DNR should mean “do not resuscitate,” not an acronym that may diminish care.

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Keywords:

do not resuscitate; do-not-resuscitate order; end-of-life care; hospice care; hospitalized patients; palliative care

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