Abstract
Few studies have examined the outcome of do-not-resuscitate (DNR) patients in surgical intensive care units (SICUs). This study deliberated the association between a DNR decision and the increased risk of death methodologically and ethically. This study was conducted in three SICUs. We collected patients’ demographic characteristics, clinical characteristics, and the status of death/survival at SICU and hospital discharge. We used Kaplan–Meier survival curves to compare the time from SICU admission to the end of SICU stay for the DNR and non-DNR patients. Differences in the Kaplan-Meier curves were tested using log-rank tests. We also conducted a Cox proportional hazards model to account for the effect of a DNR decision on mortality. We found that having a DNR order was associated with an increased risk of death during the SICU stay (aRR = 2.39, p < 0.01) after adjusting for severity of illness upon SICU admission and other confounding variables. To make the conclusion that a DNR order is causally related to an increased risk of death, or that a DNR order increases the risk of death is absolutely questionable. By clarifying this key point, we expect that the discussion of DNR between healthcare professionals and patients/surrogate decision-makers will not be hampered or delayed.
Highlights
Some studies were focused on examining the factors associated with DNR decisions
Among the 1,504 patients, 6.05% of them died in the surgical intensive care units (SICU), and 8.25% of them died in the hospital (Table 1)
This study suggested that DNR is associated with an increased risk of death after adjusting for patients’ severity of illness upon SICU admission and other confounding variables
Summary
Some studies were focused on examining the factors associated with DNR decisions. The prevalence of DNR varied from setting to setting and institution to institution, from approximately 4% to 41%4–8. Hemphill et al.’s and Shepardson et al.’s studies both showed that, for stroke patients, there was an increased risk of death for DNR patients compared with patients without DNR15,16; Kazaure et al reported that, for surgical patients, a DNR order remained an independent risk factor associated with death[17]. The studies conducted in general wards, and those conducted in intensive care units showed that a DNR decision was significantly associated with an increased risk of death[8,18]. Few of them have examined the outcome of DNR patients in surgical intensive care units (SICU) Those studies examining the association between DNR and the increased risk of death may potentially imply that DNR increases the risk of death. The objectives of this study were: (1) to examine the relationship between patients’ DNR decision and their outcome at SICU discharge after adjusting for other confounding variables; (2) to examine the relationship between the timing of DNR and the outcome; and (3) to analyze the ethical and methodological implications of the results of this study and those reported in the literature
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