Abstract 247: Trends In The Use Of DNR Orders And Timing Of Writing Orders In Patients Hospitalized With Acute Myocardial Infarction

Abstract

Aims: Several factors have led to an increase in the use of do-not-resuscitate (DNR) orders over the past decade, including the Patient Self-Determination Act, general increasing awareness of end-of-life decision making, and aging of the U.S. population. Although the characteristics of patients with DNR orders have been studied in the past, trends in the frequency and timing of DNR orders have not received much attention. The objectives of this population-based study were to examine recent (2001-2007) trends in the writing and timing of DNR orders in residents of a large central New England community hospitalized with acute myocardial infarction (AMI). Methods: Data are from the Worcester Heart Attack Study, an ongoing longitudinal study examining long-term trends in the incidence, hospital, and post-discharge case fatality rates of AMI among residents of the Worcester (MA) metropolitan area. Clinical, demographic, and medical history data, including the use and timing (prior to hospitalization vs. during hospitalization) of DNR orders, were abstracted from the medical records of patients with confirmed AMI treated at all 11 medical centers in greater Worcester during the years under study. Results: Approximately 25% (1,052 of 4,180) of patients hospitalized for AMI had a DNR order noted in their medical record. In both crude and multivariable adjusted analyses, there were no significant changes in the odds of having a DNR order written between 2001 (ref year) and 2007 (OR=1.17; 95% CI: 0.89-1.54). During this period, however, of patients who had a written DNR order, an increasing proportion had the DNR order prior to being admitted to the hospital (8.6% [25 of 292] in 2001; 54.8% [132 of 241] in 2007). In multivariable adjusted models, increasing age (≥ 85 years, OR=14.30; 95%CI10.00-20.45), history of heart failure (OR=1.67; 1.34-2.08) or stroke (OR=1.71; 1.33-2.20), and in-hospital death (OR=9.23; 6.74-12.63) were associated with having a DNR order. Only increasing age (>=85 years; OR=2.31, 1.05-5.09) and history of heart failure (OR=1.58; 1.16-2.15) were associated with having a DNR order in place prior to hospitalization. Conclusions: The results of this community-wide study of greater Worcester residents hospitalized with AMI between 2001 and 2007 suggest that the overall use of DNR orders remained stable over this period. The timing of the writing of orders changed during this period, however, with a strong trend toward DNR orders being written prior to hospitalization for AMI. We found that this increasing proportion of DNR orders written prior to admission to the hospital was largely due to advanced age and complex medical history, which may indicate that a higher number of contacts with the medical system may increase the likelihood of having a DNR order. The changing landscape of the timing of writing DNR orders for individuals with heart disease, and the factors that result in early versus later writing of orders, deserves further investigation.