Abstract
OBJECTIVE: To assess whether physicians would be more likely to override a do-not-resuscitate (DNR) order when a hypothetical cardiac arrest is iatrogenic.
DESIGN: Mailed survey of 358 practicing physicians.
SETTING: A university-affiliated community teaching hospital.
PARTICIPANTS: Of 358 physicians surveyed, 285 (80%) responded.
MEASUREMENTS AND MAIN RESULTS: Each survey included three case descriptions in which a patient negotiates a DNR order, and then suffers a cardiac arrest. The arrests were caused by the patient’s underlying disease, by an unexpected complication of treatment, and by the physician’s error. Physicians were asked to rate the likelihood that they would attempt cardiopulmonary resuscitation for each case description. Physicians indicated that they would be unlikely to override a DNR order when the arrest was caused by the patient’s underlying disease (mean score 2.55 on a scale from 1 “certainly would not” to 7 “certainly would”). Physicians reported they would be much more likely to resuscitate when the arrest was due to a complication of treatment (5.24 vs 2.55; difference 95% confidence interval [CI] 2.44, 2.91; p<.001), and that they would be even more likely to resuscitate when the arrest was due to physician error (6.32 vs 5.24; difference 95% CI 0.88, 1.20; p<.001). Eight percent, 29%, and 69% of physicians, respectively, said that they “certainly would” resuscitate in these three vignettes (p<.001).
CONCLUSIONS: Physicians may believe that DNR orders do not apply to iatrogenic cardiac arrests and that patients do not consider the possibility of an iatrogenic arrest when they negotiate a DNR order. Physicians may also believe that there is a greater obligation to treat when an illness is iatrogenic, and particularly when an illness results from the physician’s error. This response to iatrogenic cardiac arrests, and its possible generalization to other iatrogenic complications, deserves further consideration and discussion.
Similar content being viewed by others
References
Schimmel E. The hazards of hospitalization. Ann Intern Med. 1964;60:100–10.
Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304:638–42.
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370–6.
Andrews L, Stocking CB, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997;349:309–13.
Stedman’s Medical Dictionary. 24th ed. Baltimore, Md: Williams and Wilkins; 1982.
Duboise RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109:582–9.
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–84.
Mizrahi T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc Sci Med. 1984;19:135–46.
Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424–31.
Bosk C. Forgive and Remember: Managing Medical Failure. Chicago, Ill: University of Chicago Press; 1979.
Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310:118–22.
Casarett DJ, Ross LF. Overriding a patient’s refusal of treatment after an iatrogenic complication. N Engl J Med. 1997;336:1908–9.
Christakis N, Asch D. Biases in how physicians choose to withdraw life support. Lancet. 1993;342:642–6.
President’s Commission. Deciding to Forgo Life-Sustaining Treatment. Washington, DC: Government Printing Office; 1983:3.
La Puma J, Silverstein MD, Stocking CB, Roland D, Siegler M. Life-sustaining treatment: a prospective study of patients with DNR orders in a teaching hospital. Arch Intern Med. 1988;148:2193–8.
Phillips RS, Wenger NS, Teno J, et al. Choices of seriously ill patients about cardiopulmonary resuscitation: correlates and outcomes. Am J Med. 1996;100:128–37.
The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;274:1591–8.
Leape L. Error in medicine. JAMA. 1994;272:1851–7.
La Puma J, Schiedermayer D, Segler M. How can ethics consultation help resolve dilemmas about dying patients? West J Med. 1995;163:263–7.
Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089–94.
Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA. 1991;265:2815–20.
Author information
Authors and Affiliations
Additional information
Dr. Casarett is a Palliative Medicine Fellow at the University of Pennsylvania.
The MacLean Center receives financial support from the Andrew Mellon Foundation, the Field Foundation of Illinois, and the Harris Foundation.
Rights and permissions
About this article
Cite this article
Casarett, D.J., Stocking, C.B. & Siegler, M. Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic?. J GEN INTERN MED 14, 35–38 (1999). https://doi.org/10.1046/j.1525-1497.1999.00278.x
Issue Date:
DOI: https://doi.org/10.1046/j.1525-1497.1999.00278.x