ETHICS Factors Influencing DNR Decision-Making in a Surgical ICU Matthew D Bacchetta, MD, MBA, Soumitra R Eachempati, MD, FACS, Joseph J Fins, MD, FACP, Lynn Hydo, MBA, RN, Philip S Barie, MD, MBA, FACS, FCCM BACKGROUND: End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients. STUDY DESIGN: All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively. Patients who died without a DNR order were compared with patients with DNR orders. Variables in the analysis included date of DNR order, age, ICU, and hospital lengths of stay, APACHE II and III scores and maximum multiple organ dysfunction scores, past medical history, and mortality. ANOVA, multivariate ANOVA, and chi-square statistical tests were used to analyze the data, with p  0.05 used to reject the null hypothesis. RESULTS: Mortality for DNR patients was 84.7%. Multiple organ dysfunction syndrome was ubiquitous in this group of patients. There were no differences between DNR and no-DNR groups on the basis of age or APACHE III score or multiple organ dysfunction score. ICU lengths of stay were substantially higher in the patients made DNR, 1.8  0.1 versus 1.0  0.1, p = 0.0001, and 16.9  0.2 versus 12.1  1.2, p = 0.011, respectively. Multivariate ANOVA revealed that only past medical history predicted a DNR order. CONCLUSIONS: Although acuity of illness and organ dysfunction consistently predicted mortality in critically ill patient populations, only elements of the past medical history were positively associated with a DNR order in critically ill surgical patients. Additional prospective studies need to be per- formed to determine the relative influences of physiologic, demographic, and sociologic factors on the creation of DNR orders in critically ill surgical patients. (J Am Coll Surg 2006;202: 995–1000. © 2006 by the American College of Surgeons) Although there is a plethora of studies on DNR orders and end-of-life care in the general medical and medical intensive care literature, there is a relative paucity of these studies in the surgical intensive care setting. 1-3 End- of-life decisions are difficult and complex in any setting, but can be more so in the surgical setting, where major operations are part of a great effort to sustain life and reverse critical illness. 4 The withholding or withdrawing of care often seems counterintuitive to the aggressive approach inherent in surgical critical care. The obliga- tion of surgeons to their patients in undertaking an op- eration includes a duty to provide postoperative care and to “see the patient through” the postoperative course. 5 Many surgeons unilaterally suspend DNR orders dur- ing the immediate perioperative period to minimize the consequences of stress response to operation and to max- imize patient’s chance for survival. 6 After the periopera- tive period, the patient’s DNR order is often reinstated according to the patient’s or surrogate’s wishes in con- junction with the position of the American College of Surgeons Policy of DNR in the operating room. 7 The main purpose of this study was to determine the clinical factors that influenced the presence of a DNR order in the surgical ICU. Given that illness severity scoring has been shown to have predictive value for mor- tality, 8 we were specifically interested in understanding Competing Interests Declared: None. Received December 2, 2005; Revised February 9, 2006; Accepted February 20, 2006. From the Department of Surgery (Bacchetta, Eachempati, Hydo, Barie), the Division of Medical Ethics (Fins), and the Department of Public Health (Eachempati, Fins, Barie), Weill Medical College of Cornell University, New York, NY. Correspondence address: Soumitra R Eachempati, MD, FACS, New York- Presbyterian Hospital, 525 East 68 th St, Payson 718, New York, NY 10021. 995 © 2006 by the American College of Surgeons ISSN 1072-7515/06/$32.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2006.02.027