Do-not-resuscitate orders for critically ill patients in the hospital. How are they used and what is their impact?

We studied compliance with do-not-resuscitate (DNR) orders at a university hospital where a DNR protocol has existed since 1979. Documentation of DNR status in patient progress notes and chart orders increased through 1983. During a 12-month period (March 1983 through April 1984), we studied in detail the medical records of 521 patients who had a cardiopulmonary arrest in the hospital. Seventy-five percent (389 of 521) of these patients were designated DNR. Patients who were designated DNR were significantly more likely to be older, to have malignancy or an abnormal mental status, and to be less likely to have acute myocardial infarction, stroke, or chronic obstructive pulmonary disease than patients in whom resuscitation was attempted. Eighty-six percent of families, but only 22% of patients, were involved in the decision to designate a patient DNR. The decision to designate a patient DNR occurred late in the course of a patient's illness, often when the patient was in coma. For 28% of patients, some form of medical care was withdrawn or withheld after they were designated DNR. These data suggest that use of the DNR protocol requires changes if patients are to participate in the decision not to undergo cardiopulmonary resuscitation.     

An improved transilial crest bone biopsy drill for quantitative histomorphometry

Transilial crest bone biopsy with quantitative histomorphometry is an important technique for the assessment of metabolic and endocrine bone disease. The surface area of the histologic section suitable for histomorphometric analysis is reduced by the build-up of bone dust and by trabecular fracture, produced by the conventional Bordier bone drill. We describe here a modification of this drill that both allows escape of dust from around the cutting edge of the teeth and greatly reduces bone dust volume and trabecular fracture. In paired samples the new drill was shown to improve significantly the quality of the biopsy specimens.