Do not resuscitate status, not age, affects outcomes after injury

Abstract

Despite a well-described association of age and injury with mortality and decreased functional status, inpatient mortality studies have traditionally not included analysis of do not resuscitate (DNR) status. We hypothesized that the increased likelihood of DNR status in older patients alters age-adjusted mortality rates in trauma. The trauma registry was queried for adult patients admitted to our Level I trauma center (January 2005-December 2008) and divided into eight age groups by decade. Ages 15-44 years were collapsed because of the lack of variation. We compared age, case fatality rate, and DNR status by univariate analysis and trends by χ (p < 0.05). Of the 15,227 adult patients admitted, 13% were elderly (≥65) and 7% died. DNR status was known in 75% of deaths, and 42% of those had active DNR orders on the chart at time of death. DNR likelihood increased with age (p < 0.05), from 5% to 18%. With DNRs excluded, mortality variability across all ages was markedly diminished (4-7%). DNR status among trauma patients varies significantly because of inconsistent implementation and meaning between hospitals, and successive decades are more likely to have an active DNR order at time of death. When DNR patients were excluded from mortality analysis, age was minimally associated with an increased risk of death. The inclusion of DNR patients within mortality studies likely skews those analyses, falsely indicating failed resuscitative efforts rather than humane decisions to limit care after injury.