Evidence-Based Management and DNR Order Implementation

Introduction: The Imperative for Quality Decision-Making

"Culture eats strategy," the adage suggests, and in healthcare management this truth is particularly acute. Management literature across all disciplines points to the critical importance of quality decision-making. A fundamental practice problem for decision makers is that the information readily available or accessible may be incomplete, outdated, or not based on evidence. Quality decision-making is dependent on access to and use of quality information. As early computer scientists noted with the phrase "garbage in, garbage out," this principle applies directly to management decision-making. This tenet is pivotal to management in healthcare, where the stakes span from high-impact patient care decisions to the survival of medical institutions in a punishing fiscal environment.

In service-oriented organizations like hospitals, decisions are part of an interwoven network—a fabric that encompasses administrative, operational, and patient care aspects as a unified entity. Poor decisions made in any single business or care unit can create waves of repercussions felt throughout the institution. Understanding how to make sound, evidence-informed decisions is therefore not merely an efficiency concern; it is a fundamental ethical and organizational imperative.

The Problem: DNR Misinterpretation and Inadequate Palliative Care

In a large academic medical center, a significant clinical problem has come to light: patients who have Do Not Resuscitate (DNR) orders sometimes do not receive the level or scope of palliative care that could—and most likely should—be provided. Under these conditions, patients suffer needlessly, and family members have begun to complain and register unfavorable remarks on websites and social media networks. As a nurse in the acute care unit, the primary concern is that patients at end-of-life are not receiving the quality of care that the hospital identifies as central to its mission. The purpose of examining this issue is to identify the network of variables that create and sustain the problem and to provide evidence-based practice solutions to change and manage the situation.

Hospital staff have expressed concern that the problem stems from hospital procedures and from unconscious cultural bias related to patients near death. Hospital procedures may delay the receipt of palliative care, and DNR orders do not make the wishes of patients and family members sufficiently salient to hospital staff. Moreover, an underlying attitude of fatalism seems to pervade the acute care unit when a patient is identified as being at end-of-life. Additionally, medical personnel are working at maximum capacity in their dual roles as clinicians and teachers, which may contribute to communication failures and oversight.

The root cause of this problem lies in the frequent misinterpretation of "do-not-resuscitate" orders more restrictively than their original intent: simply declining cardiopulmonary resuscitation. The research literature on this topic reveals that this problem was identified approximately 20 years ago. Henneman and colleagues (1994) documented that DNR orders are often misinterpreted more restrictively than intended, even when patients were otherwise receiving aggressive medical management.

According to the research, misinterpretation of DNR orders may result from poor understanding of hospital policy, the cultural values of hospital staff, and lack of comfort discussing the matter with family members. End-of-life care in acute care and nursing home settings is often associated with unmet needs, such that patients experience pain while both patients and families experience emotional and spiritual distress. Chen and colleagues (2014) found that when medical care provided to DNR patients is clearly indicated, healthcare professionals do not blindly decrease medical care but instead provide care determined by patient and surrogate decision-makers in collaboration with healthcare professionals. In addition to the practice problem of poor symptom recognition and management, iatrogenic suffering may be commonly experienced by patients who endure procedures that no longer benefit dying patients but instead add to their pain and suffering at end-of-life.

Evidence-Based Approaches and Root Cause Analysis

Kovner and Rundall (2006) reviewed the Shewhart Plan-Do-Study-Act cycle and the generic eight-step decision-making model, arguing that important considerations are missing from both. The treatment of data gathering and fact-finding lacks depth. Decision-making is strengthened when it is derived from a well-rounded and in-depth gathering process that includes data and information from local sources, current evidence-based best practices, clinical experience, and benchmarking to other comparable institutions. Additionally, Kovner and Rundall argue that decision-making models should be updated to embed the use of information gathered from digital environments, such as the internet and electronic medical records.

An evidence-based approach typically follows a five-step process: (1) identify the research question; (2) access and review relevant research and evidence; (3) evaluate the relevance, applicability, quality, and validity of the information; and (4) present findings in a manner that is actionable and persuasive. When applied to the hospital setting, this evidence-based process overlays a root cause analysis (RCA) onto the problem of practice. This means that the following questions are asked and answered, as much as possible, by providing evidence: (1) What happened? (2) What should have happened? (3) Why did it happen? and (4) What can be done to correct the error?

Root cause analysis in the context of DNR misinterpretation reveals multiple contributing factors. It is not simply that staff lack knowledge; rather, the system itself—through its procedures, communication patterns, and embedded cultural assumptions—creates conditions under which adequate palliative care is deprioritized. By using a structured, evidence-informed approach to identify these causes, hospital leaders can move beyond blame and toward systemic solutions supported by documented best practices.

The Comfort Care Order Set Solution

A set of care guidelines known as the Comfort Care Order Set (CCOS) was devised according to best practices for care of people at end of life. The CCOS guides clinicians to ensure that patients have adequate access to medications for control of symptoms and that processes of care are modified to meet the needs of the patient at the time of treatment or care. By shifting to a comfort care order set approach, disease-managing therapies and palliative care can be continued simultaneously. While applying the CCOS, practitioners can weigh the application of restrictions and order more tests and treatments if the burdens overshadow the benefits.

Adopting the CCOS can enhance both the quality and quantity of life for patients and add to the humanitarian aspects of the education of residents and interns. Rather than forcing a false choice between aggressive medical management and palliative comfort, the CCOS framework allows clinicians to customize care based on the patient's condition, preferences, and prognosis. This approach aligns with the research evidence showing that explicit orders and clear protocols reduce misinterpretation and improve patient outcomes.