Regional and Institutional Variation in the Initiation of Early Do-Not-Resuscitate Orders
Abstract
BACKGROUND: Do-not-resuscitate (DNR) orders are an important step in decision making about aggressiveness of care for patients in hospitals. The use of DNR orders is known to vary with patient characteristics, but few studies have investigated the role of hospital factors or of regional variation. We examined these influences on the use of early DNR orders (written <24 hours after admission). METHODS: We conducted a retrospective cross-sectional study of patients 50 years and older admitted to acute-care hospitals in California in 2000 from the most prevalent medical and surgical diagnosis related groups. We performed multivariate logistic regression predicting use of DNR by hospital characteristics while accounting for patient characteristics, and estimated indirectly standardized rates of DNR use by county. RESULTS: In the selected diagnosis related groups, 819 686 persons were admitted to 386 hospitals. Early DNR orders varied from 2% (patients aged 50-59 years) to 17% (patients aged > or =80 years). In multivariate analyses, the odds of having early DNR orders written were significantly lower in for-profit (vs private nonprofit) hospitals, higher in the smallest (vs the largest) hospitals, and lower in academic (vs nonacademic) hospitals. Standardized rates of DNR order use varied 10-fold across counties. The highest rates were among patients from rural areas. However, variation in use did not correspond well to county population, hospital bed availability, or population density. CONCLUSIONS: Hospital characteristics appear to be associated with the use of DNR orders, even after accounting for differences in patient characteristics. This association reflects institutional culture, technological bent, and physician practice patterns. If these factors do not match patient preferences, then improvements in care are needed.
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Generalisability outside of Karolinska University Hospital is limited, as the use of DNACPR decisions is influenced by cultural, religious, and legal factors, as well as regional and institutional policies.
“Generalisability outside of Karolinska University Hospital is limited, as the use of DNACPR decisions is influenced by cultural, religious, and legal factors, as well as regional, and institutional policies.23., 24., 38., 39.”
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Mehta, A., Douglas, I. S., Battaglia, C. T., & Wynia, M. K. (2023) · Journal of Palliative Medicine · doi:10.1089/jpm.2023.0277 · Cited by 1 · see citing works
Alayed, T. M., Al-Sowat, W., Alturki, A., Aljofan, F., Alabdulsalam, M., Alofisan, T. O., Alhuthil, R. T., Alshalawi, M., & Alghamdi, M. (2025) · Critical Care Research and Practice · doi:10.1155/ccrp/9948312 · Cited by 1 · see citing works
Mortality as a Measure of Quality
Holloway, R. G., & Quill, T. E. (2017)
Nguyen, A., Douglas, I. S., & Mehta, A. (2026) · BMJ Supportive & Palliative Care · doi:10.1136/spcare-2025-006006
- Authors
- Zingmond, D. S., & Wenger, N. S.
- Affiliations
- University of California, Los Angeles (US)
- Venue
- Archives of Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2005-08-08
- Volume
- 165
- Issue
- 15
- Pages
- 1705
- ISSN
- 0003-9926 (ISSN-L)
- OpenAlex
- W2096545435
- Cited by
- 76
- References
- 28
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 1 · 2023: 3 · 2022: 4 · 2021: 4 · 2020: 3 · 2019: 4 · 2018: 3 · 2017: 5 · 2016: 5 · 2015: 5 · 2014: 6 · 2013: 3 · 2012: 2
- FWCI
- 3.49
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Archives of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
- Keywords
- do-not-resuscitate orders, regional variation, hospital characteristics, institutional variation, for-profit hospitals, academic medical centers, rural hospitals, older adults, end-of-life decisions, aggressive care, institutional culture
- MeSH terms
- Aged, Aged, 80 and over, California, Hospitals, Humans, Middle Aged, Retrospective Studies, Logistic Models, Resuscitation Orders, Health Care Surveys
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