Do-not-resuscitate Group Research Articles

Early Versus Late DNR Orders and its Predictors in a Saudi Arabian ICU: A Descriptive Study.

BackgroundPractices of Do-Not-Resuscitate (DNR) orders show discrepancies worldwide, but there are only few such studies from Saudi Arabia.Objective:To describe the practice of DNR orders in a Saudi Arabian tertiary care ICU.Methods:This retrospective study included all patients who died with a DNR order at the ICU of King Saud Medical City, Riyadh, Saudi Arabia, between January 1 to December 31, 2021. The percentage of early DNR (i.e., ≤48 hours of ICU admission) and late DNR (>48 hours) orders were determined and the variables between the two groups were compared. The determinants of late DNR were also investigated.Results:A total of 723 cases met the inclusion criteria, representing 14.9% of all ICU discharges and 63% of all ICU deaths during the study period. The late DNR group comprised the majority of the cases (78.3%), and included significantly more patients with acute respiratory distress syndrome (ARDS), community acquired pneumonia (CAP), acute kidney injury, and COVID-19, and significantly fewer cases of readmissions and malignancies. Septic shock lowered the odds of a late DNR (OR = 0.4, 95% CI: 0.2–0.9;P= 0.02), while ARDS (OR = 3.3, 95% CI: 2–5.4;P < 0.001), ischemic stroke (OR = 2.5, 95% CI: 1.1–5.4;P= 0.02), and CAP (OR = 2, 95% CI: 1.3–3.1;P= 0.003) increased the odds of a late DNR.Conclusion:There was a higher frequency of late DNR orders in our study compared to those reported in several studies worldwide. Cases with potential for a favorable outcome were more likely to have a late DNR order, while those with expected poorer outcomes were more likely to have an early DNR order. The discrepancies highlight the need for clearer guidelines to achieve consistency.

Early DNR in Older Adults Hospitalized with SARS-CoV-2 Infection During Initial Pandemic Surge.

The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8,P< .001), women (51.2% vs 43.6%,P= .012), with higher comorbidity index (3.88 vs 3.36,P< .001), facility-based (49.1% vs 19.1%,P < .001), with dementia (13.3% vs 4.6%,P< .001), and severely ill on presentation (57.9% vs 32.3%,P< .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10-4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40-.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21-.67), and shorter length of stay (LOS, 4.8 vs 10.3 days,P< .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85-1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40-.75), IMV (OR: 0.53, 95% CI: 0.29-.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30-.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.

Predictors, Treatments, and Outcomes of Do-Not-Resuscitate Status in Acute Myocardial Infarction Patients (from a Nationwide Inpatient Cohort Study)

Little is known about how frequently do-not-resuscitate (DNR) orders are placed in patients with acute myocardial infarction (AMI), the types of patients in which they are placed, treatment strategies or clinical outcomes of such patients. Using the United States (US) National Inpatient Sample (NIS) database from 2015 to 2018, we identified 2,767,549 admissions that were admitted to US hospitals and during the hospitalization received a principle diagnosis of AMI, of which 339,270 (12.3%) patients had a DNR order (instigated both preadmission and during in-hospital stay). Patients with a DNR status were older (median age 83 vs 65, p < 0.001), more likely to be female (53.4% vs 39.3%, p < 0.001) and White (81.0% vs 73.3%, p < 0.001). Predictors of DNR status included comorbidities such as heart failure (OR: 1.47, 95% CI: 1.45 to 1.48), dementia (OR: 2.53, 95% CI: 2.50 to 2.55), and cancer. Patients with a DNR order were less likely to undergo invasive management or be discharged home (13.5% vs 52.8%), with only 1/3 receiving palliative consultation. In hospital mortality (32.7% vs 4.6%, p < 0.001) and MACCE (37.1% vs 8.8%, p < 0.001) were higher in the DNR group. Factors independently associated with in-hospital mortality among patients with a DNR order included a STEMI presentation (OR: 2.90, 95% CI: 2.84 to 2.96) and being of Black (OR: 1.29, 95% CI: 1.26 to 1.33), Hispanic (OR: 1.36, 95% CI: 1.32 to 1.41) or Asian/Pacific Islander (OR: 1.56, 95% CI:1.49-race. In conclusion, AMI patients with a DNR status were older, multimorbid, less likely to receive invasive management, with only one third of patients with DNR status referred for palliative care.

Neonatal hospice care utilization in a tertiary hospital in Taiwan before and after the legalization of life-sustaining treatment withdrawal.

The advancements in neonatal critical care have not only improved the outcomes of extreme prematurity but also prolonged the process of death in terminally ill neonates. This study analyzed the characteristics of neonates who died at a single tertiary center in Taiwan. The utilization of neonatal hospice care before and after the legalization of life-sustaining treatment (LST) withdrawal in Taiwan in 2013 was also compared. This study enrolled the neonatal mortality cases in the Taipei Veterans General Hospital during January 2008 to December 2017 through chart review. Data on birth history, primary diagnosis, complications, and death circumstances were recorded and analyzed. In total, 105 neonatal deaths were analyzed. The circumstances of death were as follows: 22 (21%) cases of full LST and cardiopulmonary resuscitation (CPR) performed until death; 63 (60%) cases of LST initiated but no more CPR after do-not-resuscitate (DNR) consents signed; 8 (7.6%) cases of LST withdrawn; 4 (3.8%) cases of DNR signed without LST initiation; 3 (2.9%) cases of CPR not performed, although no DNR signed; and 5 (4.8%) cases of discharge against medical advice under critical condition. The incidence of written DNR consents (57.9% in 2008-2009 vs 93.8% in 2016-2017; p = 0.02) showed an increasing trend. Regarding the incidence of comorbidities, renal failure rate was higher in the DNR group than in the non-DNR group (p = 0.002). There was an increasing trend for written DNR consent and the utilization of neonatal hospice care. Renal failure, as a comorbidity, was significantly associated with the written DNR consent in the neonates. Further studies to evaluate the factors associated with neonatal hospice care utilization are suggested.

Changes in Clinical Course Before and After Do-Not-Resuscitate Order Placement in a Pediatric Intensive Care Unit Setting.

Background: The relationship between clinical course and do-not-resuscitate (DNR) status has not been well studied in the pediatric intensive care unit (PICU) setting. Objective: To describe the relationship between DNR order placement and clinical course. Design: Single center retrospective cohort study. Setting/Subjects: Patients, ages 0-18 years, who have died in the PICU from 2008 to 2016. Measurements: Retrospective chart review of DNR status, patient characteristics, and clinical course. We compared length of stay and number of consults/procedures/imaging studies done on patients with early DNR (>48 hours before death), late DNR (within 48 hours of death), and no DNR order placement. Results: One-hundred and sixty-one children were included. Nearly half (48%) were male with median (interquartile range) age of 3 years (0-12). One-third (58) had an underlying oncologic diagnosis. Eighteen percent (29/161) were classified as early DNR, 33% (53/161) as late DNR, and 49% (79/161) as no DNR. We found no differences in patient characteristics or risk of mortality at admission among the groups. The early DNR group showed decreased number of invasive procedures (0.68), imaging studies (1), and consults (0.21) per day when compared with the late (2, 1.53, 0.50) and no DNR groups (2.09, 1.73, 0.43). Conclusion: Our results suggest that early DNR placement in the PICU is associated with a change in clinical course centered around less invasive care. Earlier DNR placement can potentially trigger a shift in care goals that could improve the quality of life for patients and mitigate emotional and physical toll on patients and their families during the highly stressful end-of-life time period.

Effect of do-not-resuscitate orders on patients with sepsis in the medical intensive care unit: a retrospective, observational and propensity score-matched study in a tertiary referral hospital in Taiwan

ObjectiveThe aim of this study was to determine whether do-not-resuscitate (DNR) orders affect outcomes in patients with sepsis admitted to intensive care unit (ICU).DesignThis is a retrospective observational study.ParticipantsWe enrolled...

Impact of frailty on do-not-resuscitate orders and healthcare transitions among elderly Koreans with pneumonia.

PurposePneumonia poses a significant health risk in aging societies. We aimed to elucidate the determinative value of frailty for do-not-resuscitate (DNR) orders in pneumonia patients.Patients and methodsThis was a retrospective cohort study conducted at the Seoul National University Bundang Hospital (SNUBH) in Korea. Medical records of 431 pneumonia patients, aged 65 years and older, who were admitted between June 2014 and May 2015 were analyzed. Patients were categorized into DNR and no-DNR groups.ResultsAmong the 65 patients (15.1% of pneumonia patients) who completed DNR documents, 24 patients were survived, and 21 patients decided imminent to death (<24 hours before death), with all decisions determined by surrogates. The DNR group tended to be older and frail, with higher rates of renal impairment and malnutrition, and had a lower microbiology detection effort than the no-DNR group. The DNR group used a high number of broad-spectrum antibiotics, experienced high levels of in-hospital (63.1% vs 5.7%, P<0.001) and 30-day (64.6% vs 9.6%, P<0.001) mortality rates, and had prolonged hospital stays (median length of hospital stay, 12 vs 9 days, P=0.020). Frailty was independently associated with DNR status even after adjustment for sepsis, septic shock, and the pneumonia severity index (PSI) score. Frailty also significantly influenced healthcare setting transitions after adjustment for sepsis, septic shock, and the PSI.ConclusionWe identified the factors associated with DNR orders and their prognoses among elderly Koreans with pneumonia. Frailty was significantly associated with DNR decision and healthcare setting transitions in pneumonia patients.

Do-Not-Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score-Matched Analysis.

To explore the effect of the presence and timing of a do-not-resuscitate (DNR) order on short-term clinical outcomes, including mortality. Retrospective cohort study with propensity score matching to enable direct comparison of DNR and no-DNR groups. Large, academic tertiary-care center. Hospitalized medical patients aged 65 and older. Primary outcome was in-hospital mortality. Secondary outcomes included discharge disposition, length of stay, 30-day readmission, restraints, bladder catheters, and bedrest order. Before propensity score matching, the DNR group (n=1,347) was significantly older (85.8 vs 79.6, p<.001) and had more comorbidities (3.0 vs 2.5, p<.001) than the no-DNR group (n=9,182). After propensity score matching, the DNR group had significantly longer stays (9.7 vs 6.0 days, p<.001), were more likely to be discharged to hospice (6.5% vs 0.7%, p<.001), and to die (12.2% vs 0.8%, p<.001). There was a significant difference in length of stay between those who had a DNR order written within 24 hours of admission (early DNR) and those who had a DNR order written more than 24 hours after admission (late DNR) (median 6 vs 10 days, p<.001). Individuals with early DNR were less likely to spend time in intensive care (10.6% vs 17.3%, p=.004), receive a palliative care consultation (8.2% vs 12.0%, p=.02), be restrained (5.8% vs 11.6%, p<.001), have an order for nothing by mouth (50.1% vs 56.0%, p=.03), have a bladder catheter (31.7% vs 40.9%, p<.001), or die in the hospital (10.2% vs 15.47%, p=.004) and more likely to be discharged home (65.5% vs 58.2%, p=.01). Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.

Associations between Patient Characteristics and a New, Early Do-Not-Attempt Resuscitation Order after Intracerebral Hemorrhage

Decisions to limit care, including use of a do-not-resuscitate (DNR) order, are associated with increased risk of death after intracerebral hemorrhage (ICH). Given the value that patient surrogates place on the physician's perception of prognosis, understanding prognostic indicators that influence clinical judgment of outcomes is critical. The purpose of this study was to understand the patient variables and comorbid illnesses associated with DNR orders placed on patients within 72 hours after ICH. Single-center, retrospective review of medical records of 198 consecutive patients with an admission diagnosis of primary supratentorial ICH between July 2007 and December 2010. Patients who did not experience a DNR order placement during their primary admission for ICH (non-DNR group) were compared to patients who received a new DNR order in the first 72 hours of admission (DNR group). Patient characteristics obtained include demographic data, past medical history, clinical data pertaining to the admission for the ICH, and radiographic images. Demographic, medical, and ICH injury data during the first three days of admission were collected. Multiple differences in patient and hospital factors were found between patients receiving a new, early DNR order and those who did not receive a DNR order after ICH. In regression modeling, Caucasian race, direct admission, and higher ICH score were associated with placement of a new DNR order early in the course of injury. Race, transfer procedures, and injury severity may be important factors associated with placement of new, early DNR orders in patients after ICH.

Predictors of the Use of Specific Critical Care Therapies in Patients With Metastatic Cancer.

Understanding which factors are associated with the use of critical care therapies (CCTs) can help with clinical decision-making and goals of care discussion. The goal of this study was to describe the predictors of CCT use (eg, mechanical ventilation, tracheostomy, percutaneous endoscopic gastrostomy tube, total parenteral nutrition, acute use of dialysis) in hospitalized patients with metastatic cancer. We used the 2010 California State Inpatient Databases sponsored by the Agency for Healthcare Research and Quality to identify all hospitalizations with a diagnosis of metastatic cancer (patients aged ≥18 years). We examined the predictors of any CCT use (and invasive mechanical ventilation [IMV] use), stratified by do-not-resuscitate (DNR) status, using multivariable logistic regression models. We identified 99,085 hospitalizations involving patients with metastatic cancer; 9.4% received any CCTs and 4.7% received IMV. Predictors of CCT use in the no-DNR group included principal diagnosis of infections (vs cancer-related), greater burden of comorbidities, and presence of weight loss. Predictors of CCT use in the DNR group were similar, but also included non-white races. Liver disease was also a predictor of IMV use in the no-DNR group. Patients with metastatic lung cancer (vs breast and genitourinary) with no DNR were more likely to receive CCT (and IMV). Higher burden of comorbidities, weight loss, liver disease, lung cancer subtype, and diagnosis of infections were associated with higher odds of receiving CCTs or IMV. These findings may help clinicians determine in whom to prioritize discussions around goals of care, especially in the group without a DNR status.

High Mortality in Severe Sepsis and Septic Shock Patients with Do-Not-Resuscitate Orders in East Asia.

BackgroundSevere sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan.MethodsA retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care.ResultsSixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66–14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients.ConclusionsFrom the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients.

Rationale for physicians to propose do‐not‐resuscitate orders in elderly community‐acquired pneumonia cases

In many countries, do-not-resuscitate (DNR) orders were not legislated, partly because rationale for proposal of DNR orders have not been studied in elderly pneumonia patients with cognitive and physical disorders. The aim of the present study was to elucidate the factors influencing physicians' proposal for DNR orders and their validity as prognostic predictor, by comparing elderly pneumonia cases with and without DNR orders. Medical records of community-acquired pneumonia patients aged 65 years or older were retrospectively studied (n = 641). The patients were categorized into two groups; one with DNR orders within 72 h after admission and the other without it. DNR was decided in 183 patients (28.5%). The DNR group, containing more elderly patients with poorer performance status, showed higher rates of malnutrition, dementia, aspiration, very severe pneumonia, respiratory failure and mortality. The choice of antimicrobials was not affected by the presence of DNR orders. Mortality rate within 30 days was higher in the DNR group than in the non-DNR group (33.9% vs 2.8%, P < 0.001), as well as total hospital mortality (56.8% vs 4.8%, P < 0.001). Multiple logistic analysis identified factors involved in the decision-making of DNR orders; that is, aspiration, healthcare-associated pneumonia, respiratory failure, intensive airspace consolidation, age 75 years and older, performance status 3 and 4, and serum albumin<2.5 g/dL were positive factors for DNR orders. The present study showed factors involved in the physicians proposal of DNR orders, demonstrating that DNR was empirically chosen based on comprehensive judgment of several prognostic predictors and it, in itself, was a good prognostic predictor.

Carotid Endarterectomy in Asymptomatic Patients With Limited Life Expectancy

Conclusion: Carotid endarterectomy (CEA) is commonly performed in asymptomatic patients with life-limiting conditions. The net benefit of CEA in this population is uncertain. Summary: Numerous guidelines are in place regarding which patients with asymptomatic carotid stenosis should be considered for prophylactic CEA. The Society for Vascular Surgery guidelines indicate that asymptomatic patients with ≥60% carotid artery stenosis can be considered for CEA when life expectancy is >3 years and the perioperative stroke and death risk is <3% (Ricotta JJ et al, J Vasc Surg 2011;54e1-e31). Other societies have more strict indications and assert that appropriate candidates should have a life expectancy >5 years (Goldstein LB et al, Stroke 2011;42:517-84; and Chaturvedi S et al, Neurology 2005;65:794-801). The American Academy of Neurology (Chaturvedi S et al, reference) supports CEA for asymptomatic disease only if patients are aged <75 years. However, anecdotally, it appears many patients undergo CEA outside of societal guidelines. The authors sought to examine how commonly CEA was performed in asymptomatic patients with limited life expectancy. They used the American College of Surgeons National Quality Improvement Project data to identify eight conditions associated with limited life expectancy based on survival estimates using external sources: disseminated cancer, advanced liver disease, symptomatic congestive heart failure, dialysis dependence, severe chronic obstructive pulmonary disease, age >90 years, American Society of Anesthesiologist class 4, and do-not-resuscitate (DNR) status as indicators of limited life expectancy. The predicted 5-year mortality in all but the DNR group varies from 46% to 83%. Comparisons were then made of 30-day stroke rate, death, and myocardial infarction after CEA between asymptomatic patients with and without life-limiting conditions. There were 12,631 CEAs performed in asymptomatic patients, of which 2,525 (20%) were performed in patients with life-limiting conditions or diagnoses. The most common conditions were severe chronic obstructive pulmonary disease and American Society of Anesthesiologist class 4 designation. Patients with life-limiting conditions had higher rates of perioperative complications, including stroke, (1.8% vs 0.9%, P < .01), death (1.4% vs 0.3%, P < .01), and stroke/death (2.9% vs 1.1%, P < .001). After adjustment for other comorbidities, patients with life-limiting conditions were still nearly three times more likely to experience perioperative stroke or death than those without these conditions (odds ratio, 2.1; 95% confidence interval, 2.1-3.8; P < .001). The incidence of myocardial infarction was 1%. Comment: The data as presented in the original abstract are a bit misleading. Of the nearly 13,000 patients undergoing prophylactic CEA, the very large majority deemed to have life threatening conditions had severe chronic obstructive pulmonary disease or American Society of Anesthesiologist class 4. Only 10 patients had advanced liver disease, 21 had advanced cancer, 25 patients had a DNR status, 108 were aged >90 years, and 110 were dialysis-dependent. The decision to perform surgery is an individual one between the physician and the patient. Data such as this are never privy to individual circumstances surrounding operative decisions. For example, clearly not all 90-year-old patients and not all dialysis-dependent patients are the same. Conversely, as pointed out by the authors, the National Quality Improvement Project database may underestimate perioperative myocardial infarction and stroke. Nevertheless, although prophylactic CEA may be an overused procedure, the stroke and death rates in the patients with so-called limited life expectancy were actually less than those advocated by the American Heart Association for patients with asymptomatic carotid stenosis. Without actual survival data on the so-called patients with limited life expectancy, the report can be considered a bit more inflammatory than informative.

Circumstances surrounding end of life in a pediatric intensive care unit.

Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting. We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean +/- standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves. Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required >or=2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions. More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made.

Community-acquired pneumonia and do not resuscitate orders.

From a cohort of patients with community-acquired pneumonia (CAP) who required admission to hospital, to describe the subset of patients having a do not resuscitate (DNR) order and to compare them with those who did not have such an order. Retrospective subset analysis of data from the pneumonia patient outcomes research team study. Three hospitals in the United States and one in Canada. Hospitalized patients aged 18 and older with CAP. Sociodemographic features, severity of illness, antibiotic therapy, length of stay, mortality, admission to special care units, and mortality attributable to pneumonia. The 199 (14.9) of 1,339 inpatients with CAP who had a DNR order written within 24 hours of admission and an additional 96 (7.2) patients who had such an order written later were compared with the 1,044 who never had a DNR order. The 199 patients with an initial DNR and 96 later DNR were older (median age 81 and 78 vs 65 years, respectively; P< .001), more likely to be white (92.5 and 90.6 vs 84.8; P = .007), and more likely to have come from a nursing home or chronic care facility (53.8 and 31.3 vs 4.5; P< .001). The two DNR groups received more antibiotics for a longer time than the never DNR patients. The DNR patients had longer lengths of stay than the never DNR patients (medians 9 and 12 vs 7 days). There were 89 in-hospital deaths among the 1,339 patients, but only 11 of these were among patients who did not have a DNR order during the first 30 days (sensitivity, specificity, and positive and negative predictive values of a DNR order for in-hospital mortality were 87.6, 82.6, 26.4, and 98.9, respectively). The 90-day mortality rates were 43.2 for the initial DNR group, 61.5 in the later DNR group, and 4.7 for the never DNR group (P< .001). Pneumonia-attributable mortality accounted for most of the in-hospital deaths but did not differ by DNR status. Only 31.7 of the initial DNR patients and 24.0 of the later DNR patients were discharged home, versus 82.6 of the other patients (P< .001). In a multivariate analysis, the following were predictive of initial DNR: age, nursing home care, active cancer, dementia, neuromuscular disorders, altered mental status, low systolic blood pressure, tachypnea, abnormal hematocrit, abnormal blood urea nitrogen, and absence of alcohol or intravenous drug abuse. In similar analyses of DNR at any time, additional predictors included aspiration, low white blood count, chronic pulmonary disease, cerebrovascular disease, and congestive heart failure. Most in-hospital pneumonia deaths occur in patients who have a DNR order. DNR orders written within 24 hours of admission primarily reflect comorbid status, whereas DNR orders written later during hospitalization reflect the futility of care plus comorbidity.

Do-not-resuscitate practices in the chronically critically ill

To determine the frequency of do-not-resuscitate (DNR) orders in the chronically critically ill; to identify the differences in clinical and demographic characteristics of chronically critically ill patients who have DNR orders and those who do not; to identify the differences in the cost of care between patients with and without DNR orders; and to identify the differences in DNR practices between an experimental special care unit and the traditional intensive care unit (ICU). Randomized, prospective design with a block randomization scheme. Two hundred twenty patients who met the following eligibility criteria for enrollment in a parent study of the special care unit: an ICU stay of at least 5 days, an absence of pulmonary artery monitoring, an absence of frequent titration of intravenous vasopressors, an Acute Physiology and Chronic Health Evaluation II score of less than 18, and a Therapeutic Intervention Scoring System score of less than 39. A large, urban academic medical center. Clinical and demographic variables describing the study populations, mental status, and timing of DNR orders, mortality rates, and cost of hospitalization. There was no difference in the frequency of DNR orders between the special care unit versus the intensive care unit--although patients in the special care unit had a longer interval between hospital admission and initiation of the DNR order. DNR patients differed from non-DNR in that they were older, less likely to be married, and had a higher Acute Physiology and Chronic Health Evaluation II score on admission to the study. The mortality rate in the DNR group was 71% versus 6% in the non-DNR group. There was no difference in total costs. DNR patients were also more likely to have an impaired mental status on admission, and more likely to have deterioration in mental status by the time of discharge than the non-DNR patients.

Critical care nurses' perceptions of appropriate care of the patient with orders not to resuscitate

To determine critical care nurses' perceptions of appropriate care of patients with and without do-not-resuscitate (DNR) orders. Descriptive, cross-sectional. Large, northeastern, metropolitan teaching hospital. Eighty-seven staff nurses divided into DNR and non-DNR groups whose demographic characteristics were coincidentally similar. Responses to an original questionnaire. Questionnaires describing one of two hypothetical patients (DNR or non-DNR) were distributed to all available staff nurses working in adult intensive care units. After construct validity and internal consistency reliability were established (Cronbach's coefficient alpha = 0.84 for the physical subscale, 0.79 for the psychosocial), analysis of variance was used in the data analysis. Mean total scores were 60.7 for the DNR group and 69.6 for the non-DNR group (p = 0.0031). Mean scores on the physical subscale were 33.6 and 41.9 for the DNR and the non-DNR groups, respectively (p = 0.0032). Results on the psychosocial subscale showed no significant differences between the groups. Item analysis showed significant differences on weighing the patient (p = 0.0002), monitoring neurologic status (p = 0.0082), drawing blood cultures (p = 0.0094), checking vital signs (p = 0.0071), performing complete nursing assessments (p = 0.0179), and treating the patient in an intensive care unit (p = 0.0001). Compared with the patient without a DNR order, significantly lower levels of agreement were expressed with interventions involving monitoring for the patient with the DNR order. Agreement with placement of the patient with the DNR order in an intensive care unit may be seen to follow the same pattern. Education of caregivers and communication among them might help to clarify what may be ambiguous policies and orders.

Code status decision-making in a nursing home population: processes and outcomes.

To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions. Retrospective uncontrolled observational study carried out through record review. A single skilled-level teaching NH and its affiliated university hospital. All of the 350 individuals who resided at the NH during a 2-year period. Code status decisions were routinely sought through discussion involving primary care physician/social worker teams and residents or surrogates of demented patients. Choices were made for 80% of the NH residents, most (73%) by surrogates and most (80%) for do-not-resuscitate (DNR) orders, usually within 10 weeks of NH admission. Neither short-term measures of NH care intensity nor hospital use changed after a DNR decision. Most (80%) hospital transfer records included code status documentation. At the NH, both the likelihood of decisions and their directions were associated with involvement by specific physician/social worker teams. Additionally, a dementia diagnosis, white race, and older age were associated with a nursing home DNR decision. At the hospital, a DNR order was associated with white race, the presence of nursing home DNR documentation in the transfer records, hospital attending care by certain NH physicians, and a terminal hospital stay. Hospital inpatient medical and surgical therapy use, except for intensive care procedures, was similar for DNR and non-DNR inpatients. Residents with DNR orders had a higher mortality rate, yet most survived at least 1 year after the order. In the short term, a DNR order had no impact on measured health care resource consumption, but, for those in the final months of life, in-patient hospital use was less for the DNR group, and most of these died at the nursing home. Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.