Document Type

Original Report


Bioethics and Medical Ethics | Critical Care | Critical Care Nursing | Higher Education | Medical Education | Medicine and Health Sciences | Palliative Care | Palliative Nursing | Patient Safety | Social Justice


Background: Code status orders are important features of patient-centered clinical decisions, patient autonomy, and end-of-life care. Despite proper documentation of “do not resuscitate” (DNR) code status, hospitalized patients may be subjected to cardiopulmonary resuscitation (CPR) efforts that go against their wishes.

Purpose: The objective of this study was to identify and describe the population of hospitalized patients receiving discordant resuscitation efforts at a Midwest academic medical center utilizing electronic health records (EHR).

Method: The study included EHR records between 01/01/2011 and 01/01/2021 for hospitalized patients 19 years and older who experienced cardiac arrest (ICD-10 I46) and were documented as DNR. Patients younger than 19 years of age and those with full code status were excluded.

EPIC’s “code narrator” was queried for records meeting the inclusion criteria. Using the code start and stop time along with the timestamp of their code status order, patients who were DNR at the time of the code start time were included, and all others were excluded.

Results: Thirteen of 112 (11.6%) DNR patients who experienced cardiac arrest had CPR performed, with two patients experiencing discordant resuscitation twice. Patients who experienced resuscitation efforts discordant with their code status were 53.8% female and 84.6% White, with a median age of 82 years old (47 - 94 years). Median code duration was 16.9 minutes (1.7 - 50.9 minutes) with 9.89 minutes (5 - 50.9 minutes) of chest compressions. Average length of code status prior to code start time was 1.66 days. Seven of 15 (46.7%) CPR events resulted in return of spontaneous circulation (ROSC).

Conclusion: Discordant in-hospital resuscitation efforts contribute to significant patient harm and moral distress. Thirteen unique patients whose resuscitation wishes were not followed were identified. Long term goals of this project are to investigate possible causes of these events and develop solutions.




Advanced Directives, Cardiopulmonary Resuscitation, CPR, Do not attempt resuscitation, Do not resuscitate, DNR, discordant, code status, end-of-life care, resuscitation orders, cardiac arrest

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Table 1.pdf (74 kB)
Epic code status procedure codes

Figure 1.pdf (90 kB)
Identifying patients who experienced cardiac arrest with active DNR code status

Figure 2.pdf (88 kB)
Demographic breakdown of inappropriately resuscitated patients

Figure 3.pdf (89 kB)
Resuscitation characteristics of inappropriately resuscitated patients

Figure 4.pdf (90 kB)
Advanced care planning characteristics of inappropriately resuscitated patients



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