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Citing inconsistencies in how patients' end-of-life choices are carried out, Duke Medicine researchers are calling for changes in the system of do-not-resuscitate orders.

The researchers say a statewide system is needed that would allow DNR and other end-of-life orders to follow a patient regardless of his or her movement from one health care setting to another. Now, a new order may be needed each time the patient enters a different health care facility.

"It is a sad commentary on our priorities that dying patients who are transferred from one institution to another are more likely to arrive with their laboratory studies than documentation outlining their preferences for end-of-life care," said Judith Payne, Ph.D., assistant professor at the Duke University School of Nursing.

Payne and Deirdre Thornlow, Ph.D., also an assistant professor at the Duke University School of Nursing, co-authored a recent article in the Journal of Gerontological Nursing.

"Transitions in care across settings often provoke angst -- for everyone involved," Thornlow said. "At a minimum, let's be sure that patients nearing their end of life receive the treatment they want, but aren't subjected to treatment they don't want. Portable DNR and end-of-life orders offer consistent mechanisms to ensure patients' wishes are consistently followed, regardless of setting."

Even as patients and families worry that their end-of-life choices will not be honored, many doctors and other health care professionals lack knowledge of DNR orders and find them confusing, Payne and Thornlow said. That is especially true, they say, in cases involving older adults and those with chronic or terminal illnesses -- despite recent progress in the law and use of advance directives.

An advance directive is a statement prepared and signed by a patient or his legal representative stating the kind of care he wants to receive in the event something happens that prevents him from making his wishes known. A DNR is a written medical order that documents a patient's wishes regarding resuscitation and, more specifically, the patient's desire to avoid cardiopulmonary resuscitation.

Even if an advance directive declares a patient's desire to avoid CPR, it is not a DNR order. A DNR order must be written by a physician or advanced practice nurse on a specific medical order form. An advance directive tells health care providers the level of care a patient wants; a physician order instructs other health care providers about the level of care to provide.

"Policies on resuscitation must acknowledge that time and circumstances will foreclose the possibility of a conversation between patient and physician or advanced nurse practitioner in some cases," Payne said. "This will be true not only for patients brought into the emergency room, but also for patients who have no prior relationship with health care professionals and who suffer a cardiac or respiratory arrest shortly after being admitted to the hospital. Physicians and advanced nurse practitioners are frequently unaware of their patients' desires regarding end-of-life care."

Portable DNR and end-of-life orders -- whether paper or bracelets, as are more common today, or increasingly via electronic means in the future -- offer protections that patients' wishes will be transferred quickly and consistently, Thornlow said.

"They offer mechanisms for patients and their loved ones to not only communicate important end-of-life wishes to providers, but to also facilitate consistent adherence to those wishes across care settings," she said.

Health care organizations should invest resources to help patients and providers better understand the DNR process and concept of portable DNR orders, Payne and Thornlow said.