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Original Investigation |

Clinician Perspectives Regarding the Do-Not-Resuscitate Order

Amy Sanderson, MD1; David Zurakowski, PhD1; Joanne Wolfe, MD, MPH2,3
[+] Author Affiliations
1Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
2Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
3Division of Pediatric Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
JAMA Pediatr. 2013;167(10):954-958. doi:10.1001/jamapediatrics.2013.2204.
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Importance  While data exist regarding the frequency and timing of the do-not-resuscitate (DNR) order in children, little is known about clinician attitudes and behaviors regarding this order.

Objective  To identify clinician attitudes regarding the meaning, implication, and timing of the DNR order for pediatric patients.

Design  Physicians and nurses from practice settings where advance care planning typically takes place were surveyed regarding their attitudes and behaviors about DNR orders.

Results  In total, 107 physicians and 159 nurses responded to the survey (N = 266). There was substantial variability in the interpretation of the DNR order. Most clinicians (66.9%) believe that a DNR order indicates limitation of resuscitative measures only on cardiopulmonary arrest. In reality, however, more than 85% believe that care changes beyond response to cardiopulmonary arrest, varying from increased attention to comfort to less clinician attentiveness. In addition, most clinicians reported that resuscitation status discussions take place later in the illness course than is ideal.

Conclusions and Relevance  Clinicians use the DNR order not only as a guide for therapeutic decisions during a cardiopulmonary arrest but also as a surrogate for broader treatment directives. Most clinicians believe that DNR discussions should take place earlier than they actually do. Interventions aimed at improving clinician knowledge and skills in advance care discussions as well as the development of orders that address overall goals of care may improve care for children with serious illness.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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