Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker.

OBJECTIVES To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions. DESIGN Retrospective cohort study. SETTING Large, urban, public hospital. PARTICIPANTS Hospitalized adults aged 65 and older over a 3-year period (1/1/2004-12/31/2006) with a DNR order during their hospital stay. MEASUREMENTS Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders. RESULTS Of 668 patients, the ordering physician indicated that the DNR decision was made with the patient in 191 cases (28.9%), the surrogate in 389 (58.2%), and both in 88 (13.2%). Patients who required a surrogate were more likely to be in the intensive care unit (62.2% vs 39.8%, P<.001) but did not differ according to demographic characteristics. By hospital Day 3, 77.6% of patient decisions, 61.9% of surrogate decisions, and 58.0% of shared decisions had been made. In multivariable models, the number of days from admission to DNR order was higher for surrogate (odds ratio (OR)=1.97, P<.001) and shared decisions (OR=1.48, P=.009) than for patient decisions. The adjusted hazard ratio for hospital death was higher for patients with surrogate than patient decisions (2.61, 95% confidence interval (CI)=1.56-4.36). Patients whose DNR orders were written on Day 6 or later were twice as likely to die in the hospital (OR=2.20, 95% CI=1.45-3.36) than patients with earlier DNR orders. CONCLUSION For patients who have a DNR order entered during their hospital stay, order entry occurs later when a surrogate is involved. Surrogate decision-making may take longer because of the greater ethical, emotional, or communication complexity of making decisions with surrogates than with patients.