Unintended Consequences of Code Status in the Intensive Care Unit: What Happens After a Do-Not-Resuscitate Order Is Placed? A Retrospective Cohort Study.

Abstract

Background: Some clinicians suspect that patients with do-not-resuscitate (DNR) orders receive less aggressive care. Extrapolation from code status to goals of care could cause significant harm. This study asked the question: Do DNR orders in the intensive care unit (ICU) lead to a decrease in invasive interventions? Methods: This was a retrospective cohort study of ICU patients from three teaching hospitals. All ICU patients were assessed for inclusion. Exclusion criteria were medical futility and death, comfort care, or ICU discharge <48 hours after DNR initiation. Five hundred thirty-six patients met inclusion criteria. One hundred forty-five were included in the final analysis. Primary outcomes were occurrence of invasive interventions after DNR initiation-surgical operation, central line, ventilation, dialysis, or other procedure. Secondary outcomes were antibiotic administration, blood transfusion, mortality, and discharge location. Results: Patients with DNR orders underwent fewer surgical operations (14.5% vs. 31.1%, p = 0.002), but more central lines (42.1% vs. 23.0%, p = 0.009), ventilator use (49.0% vs. 18.9%, p < 0.001), and dialysis (20.0% vs. 4.1%, p = 0.002), compared with patients without DNR orders. Transfusions and antibiotic use decreased similarly over admission for both groups (transfusions: β = 1.25; p = 0.59; and antibiotics: β = 1.44; p = 0.27). Mortality and hospice discharges were higher for DNR patients (p < 0.001.). Conclusions: DNR status did not decrease the number of nonoperative interventions patients received as compared with full code counterparts. Although differences in populations existed, patients with DNR orders were likely to receive a similar number of invasive interventions. This finding suggests that providers do not wholesale limit these options for patients with code status limitations.