Effect of New York State’s Do-Not-Resuscitate Legislation on In-Hospital Cardiopulmonary Resuscitation Practice RUSSELL S. KAMER,M.D., EILEENM. DIECK,M.D., JOHNA. MCCLUNG,M.D., PATRICIA A. WHITE,M.D., STEVEN L. SIVAK,M.D. Valhalla, New York

E

PURPOSE: On April 1,1988, New York State enacted legislation governing the withholding of cardiopulmonary resuscitation (CPR). Suggestions that the mandated protocol for withholding CPR is too cumbersome and will result in an increase in CPR attempts led us to study the effect of the new law on in-hospital resuscitation practice. PATIENTS

AND

METHODS:

we

retrOSpe&Vely

ffective April 1, 1988, New York became the first state to legislate the conditions governing the withholding of cardiopulmonary resuscitation (CPR) [l]. The state legislature enacted these strict regulations in response to a grand jury’s finding that a New York hospital had devised a policy of secret “do-notresuscitate” (DNR) orders not recorded in the medical record and issued without consulting the patient or family [2]. In addition to addressing the problem of withholding CPR without consent, the legislation was meant to ensure the issuance of a DNR order when medically appropriate and consistent with the patient’s wishes [3]. Although the law is intended to benefit patients by protecting their autonomy, some have speculated that the law may actually harm patients. It has been suggested that the legislation may lead to more attempts at resuscitation because the mandated protocol for withholding CPR is perceived as too cumbersome [4]. This study examined whether New York State’s DNR law has changed in-hospital resuscitation practice. Have resuscitation attempts increased? Are patients more involved in the DNR decision? Has the documentation of the decision to withhold CPR improved?

re-

viewed the charts of 245 adult in-patients at a county teaching hospital who died during threemonth periods before and after the law took effect. RESULTS: There was a Stati&ica.Ry nonsignificant decline in the frequency of CPR attempts at the time of death, from 59 (50%) of 119 patients in 1987 to 57 (45%) of 126 patients in 1988. Use of explicit written “do-not-resuscitate” (DNR) orders increased significantly from 13 (22%) of 60 patients who died without CPR in 1987 to 64 (93%) of 69 patients in 1988. Patient and family involvement in decisions to withhold CPR was common before the law and did not change significantly. CONCLUSION: Although changing the way DNR decisions are documented, the legislation resulted in no significant change either in the frequency of CPR or in the degree to which patients are involved in these decisions.

Summary of the Law Every patient is presumed to consent to CPR, unless there is consent to the issuance of a DNR order. If the patient has decision-making capacity, the attending physician must obtain the patient’s consent in ;:;eyesence of two witnesses before issuing a DNR If the patient lacks decision-making capacity, two physicians must certify, in writing, their opinions concerning the cause and probable duration of the patient’s incapacity. Notice of this determination must be given to the patient and the surrogate decisionmaker (legal guardian or-next of kin). Then, the surrogate may consent to a DNR order only after the written determination by two physicians that: (1) the patient has a terminal condition; or (2) the patient is irreversibly comatose; or (3) resuscitation is medically futile; or (4) resuscitation would impose an extraordinary burden in light of the expected outcome. For acute-care hospitalizations, the DNR order must be reviewed every three days.

PATIENTS AND METHODS From the Section of General Internal Medicine, Department of Medicine, Westchester County Medical Center, and the Alfred E. Smrth institute on Human Values in Medical Ethics, New York Medical College, Valhalla, New York. This work was presented in part at the International Congress on Ethics and Medicme, Stockholm, Sweden, September 1989. Requests for reprints should be addressed to Russell S. Kamer, M.D., Department of Medicine, Westchester County Medical Center, Valhalla, New York 10595. Manuscript submitted August 3. 1989, and accepted in revised form December 6. 1989. I

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1990

The American

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This study was conducted at the acute-care hospital of the Westchester County Medical Center, a major teaching hospital of New York Medical College. This facility is a tertiary referral center and comprises 476 nonpsychiatric beds. Physician staffing is provided by full-time faculty, and part-time private physicians, in concert with house officers in training. On April 1, 1988, a resuscitation protocol identical to state law in 88

DO-NOT-RESUSCITATE

all of its details was instituted. Previously, there was no formal DNR policy. Two groups of patients were evaluated in this retrospective study. The first group included all adult inpatients who died during a three-month period (October 1,1987, to December 31,1987) prior to the implementation of the DNR law. This group was compared with adult inpatients who died during the same three months one year later, after the law took effect. Charts were reviewed for the following information: age; sex; service (medical or surgical); diagnosis; presence of a DNR order on the order sheet; documentation of DNR status in the progress notes; who (resident or attending physician) spoke to the patient or family about withholding CPR; and hospital course. After implementation of the law, a subsample of cases in which a surrogate decision-maker had consented to a DNR order on behalf of the patient was reviewed for attending physician’s certification of the nature of the patient’s lack of decision-making capacity, concurring physician’s certification, surrogate decision-maker’s written consent to a DNR order, and witnesses’ signatures. Notations such as “No heroic measures” and “Supportive care only” were interpreted as evidence of DNR status in the progress notes; however, only explicit directives to withhold CPR were counted as evidence of a DNR order on the order sheet. Deaths were classified as cancer-related if the patient had a diagnosis of cancer (e.g., a patient dying of sepsis during chemotherapy for leukemia would be classified as having a cancer-related death). The chi-square test with Yates’ correction was used for categorical data, and p CO.05 was considered significant. Confidence intervals were calculated by standard formulas.

LEGISLATION

/ KAMER ET AL

TABLE I Frequency of CPR at Time of Death before and after Legislation, by Diagnosis

Diagnosis

Number (%) of Resuscitation Attempts 1987 1988

Change, % (95% confidence interval)

Cancer Other All patients

21(37) 38 (60) 59 (50)

-9 (-28 to 7) -l (-18 to 16) -5(-17to8)

16(28) 41(59) 57 (45)

TABLE II Documentation of the Decision to Withhold CPR

DNR Status Written On Order sheet Progress note ororder sheet

Charts (%) 1987 1988

Change, 46 (95% confidence interval)

93 99

71 (59 to 83) 1 (-4 to 5)

z;

1 TABLE Ill Involvement of Patients and Families in the Decision Not to Resuscitate for Patients Who Died without a Resuscitation Attempt

Decision Discussed With Patient Family, not patient Patient orfamily

Patients (96) 1987 1988 16 2 97

;:

Change, % (95% confidence interval) 3 (-10 to 15) -2 (-15 to 10) 0 (-5 to 6)

RESULTS The medical records of 245 of 258 patients who died during the study periods were available for analysis. The study group included 132 (54%) men and 113 (46%) women. The mean age was 61.4 years (range: 22 to 98 years). Table I shows a nonsignificant decline in the use of CPR after the DNR law was implemented. Table II displays a substantial and significant (p