Original Article

CME Article: Impact of Do-Not-Resuscitate Orders on Nursing Clinical Decision Making

Authors: Rebecca Engels, MD, MPH, Casey Graziani, MD, Ixavier Higgins, BS, Jessica Thompson, NP, Roberta Kaplow, PhD, APRN-CCNS, Theresa E. Vettese, MD, Annie Massart, MD


Objectives: Code status specifies the action that healthcare providers should take in the event of cardiac arrest. Studies have shown, however, that patients with do-not-resuscitate/do-not-intubate (DNR/DNI) orders have worse outcomes and do not consistently receive the standard of care. Several studies have demonstrated that physicians behave differently toward patients with DNR/DNI orders, but little research exists into whether DNR/DNI status affects the practice of other members of the care team. Our objective was to determine whether code status affects decision making by nursing staff.

Methods: This was an anonymous, self-administered survey of nurses between April 2018 and March 2019 using SurveyMonkey. The survey contained four previously published clinical vignettes followed by a series of questions regarding specific interventions tailored to reflect nursing escalation of care. Our focus was two local hospitals: one large academic quaternary-referral center and one large community hospital. Registered nurses on medical-surgical units identified based on available unit-specific e-mail listservs from both hospitals were the participants. Nurses in higher-acuity units were excluded.

Results: Nurses are significantly less likely to call rapid response or a physician when a patient undergoes certain changes in clinical status if the patient is labeled as DNR/DNI rather than full code. For all of the vignettes, respondents were less likely to say they would call rapid response or a physician for patients with a DNR/DNI status who developed tachycardia (P < 0.001). Nurses also were less likely to escalate care for patients with DNR/DNI status who developed tachypnea or mental status changes. Nurses were equally likely to call a physician for the development of abdominal pain or new hypotension (P > 0.05). Nurses with >3 years of experience were less likely to escalate care throughout the vignettes (odds ratio <1).

Conclusions: This study is the first to demonstrate that code status affects decision making by nursing staff. It highlights the limitations that code status designations create with regard to patient care. By acknowledging that patients with DNR/DNI orders receive different care, we can create systems in which patients are treated equally, regardless of their code status.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Burns JP, Truog RD. The DNR order after 40 years. N Engl J Med 2016;375:504-506.
2. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). V. Medicolegal considerations and recommendations. JAMA 1974;227(suppl):864-868.
3. Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl J Med 1976;295:364-366.
4. Miles SH, Cranford R, Schultz AL. The do-not-resuscitate order in a teaching hospital: considerations and a suggested policy. Ann Intern Med 1982;96:660-4.
5. Hickman SE, Tolle SW, Brummel-Smith K, et al. Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status. J Am Geriatr Soc 2004;52:1424-1429.
6. Brett AS. Limitations of listing specific medical interventions in advance directives. JAMA 1991;266:825-828.
7. Ehlenbach WJ, Curtis JR. The meaning of do-not-resuscitation orders: a need for clarity. Crit Care Med 2011;39:193-194.
8. Wenger NS, Phillips RS, Teno JM, et al. Physician understanding of patient resuscitation preferences: insights and clinical implications. J Am Geriatr Soc 2000;48(suppl 1):S44-S51.
9. Chen JL, Sosnov J, Lessard D, et al. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J 2008;156:78-84.
10. Jackson EA, Yarzebski JL, Goldberg RJ, et al. Do-not-resuscitate orders in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study. Arch Intern Med 2004;164:776-783.
11. Mohammed MA, Mant J, Bentham L, et al. Comparing processes of stroke care in high- and low-mortality hospitals in the West Midlands, UK. Int J Qual Health Care 2005;17:31-36.
12. Wenger NS, Pearson ML, Desmond KA, et al. Outcomes of patients with do-not-resuscitate orders. Toward an understanding of what do-not-resuscitate orders mean and how they affect patients. Arch Intern Med 1995;155:2063-2068.
13. Brovman EY, Walsh EC, Burton BN, et al. Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures. J Clin Anesth 2018;48:81-88.
14. Beach MC, Morrison RS. The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc 2002;50:2057-2061.
15. Stevenson EK, Mehter HM, Walkey AJ, et al. Association between do not resuscitate/do not intubate status and resident physician decision-making. A national survey. Ann Am Thorac Soc 2017;14:536-542.
16. Uhlmann RF, Cassel CK, McDonald WJ. Some treatment-withholding implications of no-code orders in an academic hospital. Crit Care Med 1984;12:879-881.
17. Sanderson A, Zurakowski D, Wolfe J. Clinician perspectives regarding the do-not-resuscitate order. JAMA Pediatr 2013;167:954-958.
18. Oɻ H, Scarlett S, Brady A, et al. Do-not-attempt-resuscitation (DNAR) orders: understanding and interpretation of their use in the hospitalised patient in Ireland. A brief report. J Med Ethics 2018;44:201-203.
19. Douw G, Schoonhoven L, Holwerda T, et al. Nurses' worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. Crit Care 2015;19:230.
20. Kalliokoski J, Kyngas H, Ala-Kokko T, et al. Insight into hospital ward nurses' concerns about patient health and the corresponding medical emergency team nurse response. Intensive Crit Care Nurs 2019;53:100-108.
21. Rew L, Barrow EM, Jr. State of the science: intuition in nursing, a generation of studying the phenomenon. ANS Adv Nurs Sci 2007;30:E15-E25.
22. Hodgetts TJ, Kenward G, Vlachonikolis IG, et al. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54:125-131.
23. Fieselmann JF, Hendryx MS, Helms CM, et al. Respiratory rate predicts cardiopulmonary arrest for internal medicine inpatients. J Gen Intern Med 1993;8:354-360.
24. Goldhill DR, McNarry AF, Mandersloot G, et al. A physiologically-based early warning score for ward patients: the association between score and outcome. Anaesthesia 2005;60:547-553.
25. Bilgin H, Kutlay O, Cevheroglu D, et al. Knowledge about pulse oximetry among residents and nurses. Eur J Anaesthesiol 2000;17:650-651.
26. Lee A, Bishop G, Hillman KM, et al. The medical emergency team. Anaesth Intensive Care 1995;23:183-186.
27. Salvatierra G, Bindler RC, Corbett C, et al. Rapid response team implementation and in-hospital mortality. Crit Care Med 2014;42:2001-2006.
28. Salvatierra GG, Bindler RC, Daratha KB. Rapid response teams: is it time to reframe the questions of rapid response team measurement? J Nurs Scholarsh 2016;48:616-623.
29. Foraida MI, DeVita MA, Braithwaite RS, et al. Improving the utilization of medical crisis teams (condition C) at an urban tertiary care hospital. J Crit Care 2003;18:87-94.
30. Galhotra S, Scholle CC, Dew MA, et al. Medical emergency teams: a strategy for improving patient care and nursing work environments. J Adv Nurs 2006;55:180-187. 31. Jones L, King L, Wilson C. A literature review: factors that impact on nurses' effective use of the medical emergency team (MET). J Clin Nurs 2009;18:3379-3390.
32. Rosseter R. American Association of Colleges of Nursing: The Voice of Academic Nursing, April 2019. News & Information. www.aacnnursing.org/News-Information/Fact-Sheets/Enhancing-Diversity. Accessed June 1, 2020.
33. Barter C, Renold E. The use of vignettes in qualitative research. Soc Res Update 1999;(25).
34. Jesus JE, Allen MB, Michael GE, et al. Preferences for resuscitation and intubation among patients with do-not-resuscitate/do-not-intubate orders. Mayo Clin Proc 2013;88:658-665.
35. Gehlbach TG, Shinkunas LA, Forman-Hoffman VL, et al. Code status orders and goals of care in the medical ICU. Chest 2011;139:802-809.
36. Vanpee D, Swine C. Scale of levels of care versus DNR orders. J Med Ethics 2004;30:351-352.
37. Truog RD. Do-not-resuscitate orders in evolution: matching medical interventions with patient goals. Crit Care Med 2011;39:1213-1214.
38. Sulmasy DP, Geller G, Faden R, et al. The quality of mercy. Caring for patients with 'not resuscitate' orders. JAMA 1992;267:682-686.
39. Sulmasy DP, Terry PB, Faden RR, et al. Long-term effects of ethics education on the quality of care for patients who have do-not-resuscitate orders. J Gen Intern Med 1994;9:622-626.
40. Bennett MP, Lovan S, Hager K, et al. A one hour teaching intervention can improve end-of-life care. Nurse Educ Today 2018;67:93-99.