February 28, 1994

Evaluation of a Treatment Limitation Policy With a Specific Treatment-Limiting Order Page

Author Affiliations

From the Division of General Internal Medicine, Department of Medicine (Drs O'Toole, Youngner, and Landefeld and Ms Juknialis), and Department of Medical and Surgical Nursing (Ms Daly), University Hospitals of Cleveland (Ohio); Case Western Reserve University School of Medicine, Cleveland (Drs O'Toole, Youngner, and Landefeld); and Cleveland State University (Dr Bartlett).

Arch Intern Med. 1994;154(4):425-432. doi:10.1001/archinte.1994.00420040091013

Background:  Concerns about misinterpretation, misunderstanding, poor communication, and lack of documentation prompted a revision of our hospital's treatment limitation policy. The revised policy was designed to explicate do-not-resuscitate (DNR) orders, structure the use of DNR and other treatment-limiting orders in a logical and standard way, and improve communication. Use of a Specific Treatment-Limiting Order Page (STOP) was required.

Methods:  To evaluate the policy's effects, we conducted (1) a prospective cohort study (involving 2733 patients) of treatment limitation practices before and after the new policy and (2) cross-sectional surveys of 58 nurses and 62 physicians. Outcome measures included documented treatment-limiting orders, documented discussions of these decisions, and deaths. Staff opinions about effects on communication and patient care were elicited.

Results:  Rates of death (5.4% before and 5.6% after the policy; P=.80) and rates of DNR orders (9.3% vs 9.2%, P=.9) did not change. The use of the STOP enhanced the clarity of DNR orders and, among DNR patients, greatly increased the frequency of orders limiting 12 other specific treatments for conditions short of arrest. For example, before the policy, orders prohibited mechanical ventilation in 2% of DNR patients, compared with 66% after the policy (P<.001). Staff reported that the policy improved communication among health professionals, patients, and families.

Conclusions:  The treatment limitation policy with the STOP improved documentation and communication of treatment-limiting decisions. On the basis of our results, we offer a STOP for use and evaluation by others.(Arch Intern Med. 1994;154:425-432)