Early Do-not-resuscitate Research Articles

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.

Disparities in Functional Outcome After Intracerebral Hemorrhage Among Asians and Pacific Islanders.

Disparities in outcome after intracerebral hemorrhage (ICH) among Asians, Native Hawaiians, and other Pacific Islanders (NHOPI) have been inadequately studied. We sought to assess differences in functional outcome between Asians and NHOPI after ICH. A multiracial prospective cohort study of ICH patients was conducted from 2011 to 2016 at a tertiary center in Honolulu, HI, USA to assess racial disparities in outcome after ICH. Favorable outcome was defined as 3-month modified Rankin Scale (mRS) score ≤2. Patients with no available 3-month functional outcome, race other than Asians and NHOPI, and baseline mRS > 0 were excluded. Multivariable analyses using logistic regression were performed to assess the impact of race on favorable outcome after adjusting for the ICH Score, early do-not-resuscitate (DNR) order and dementia/cognitive impairment. A total of 220 patients (161 Asians, 59 NHOPI) were studied. Overall, 65 (29.5%) achieved favorable outcome at 3 months. NHOPI were younger than Asians (p < 0.0001) and had higher prevalence of diabetes (p = 0.007), obesity (p < 0.0001), and lower prevalence of dementia/cognitive impairment (p = 0.02), early DNR order (p = 0.0004), and advance directive presence (p = 0.0005). NHOPI race was a predictor of favorable outcome in the unadjusted model [odds ratio (OR) 2.47, 95% confidence interval (CI): 1.32-4.62] and after adjusting for the ICH Score (OR 2.30, 95% CI: 1.06-4.97) but not in the final model (OR 2.04, 95% CI: 0.94-4.42). In the final model, the ICH Score was the only independent negative predictor of outcome (OR 0.26, 95% CI: 0.17-0.41 per point). NHOPI are more likely to achieve favorable functional outcome after ICH compared with Asians even after controlling for ICH severity. However, this association was attenuated by the DNR and dementia/cognitive impairment status.

Different utilization of intensive care services (ICSs) for patients dying of hemorrhagic and ischemic stroke, a hospital-based survey.

The intensive care service (ICS) saves lives and rescues the neurological function of stroke patients. We wondered the different utilization of ICS for patients with ischemic and hemorrhagic stroke, especially those who died within 30 days after stroke.Sixty-seven patients died during 2011 to 2015 due to acute stroke (42 due to intracranial hemorrhage [ICH]; 25 due to cerebral infarct [CI]). The durations of hospital stay (hospital staying days [HSDs]) and ICS staying days (ISDs) and codes of the do-not-resuscitate (DNR) were surveyed among these medical records. Statistics included chi-square and descriptive analyses.In this study, CI patients had a longer HSD (mean 14.3 days), as compared with ICH patients (mean 8.3 days); however, the ICH patients had a higher percentage of early entry within the first 24 hours of admission into ICS than CI group (95.1% vs 60.0%, P = .003). A higher rate of CI patients died in holidays or weekends than those with ICH (44.0% vs 21.4%, P = .051). DNR, requested mainly from direct descendants (children or grandchildren), was coded in all 25 CI patients (100.0%) and 38 ICH patients (90.5%). More cases with early DNR coded within 24 hours after admission occurred in ICH group (47%, 12% in CI patients, P = .003). None of the stroke patient had living wills. Withhold of endotracheal intubation (ETI) occurred among CI patients, more than for ICH patients (76.0% vs 18.4%, P < .005).In conclusion, CI patients longer HSD, ISD, higher mortality within holidays or weekends, and higher ETI withhold; but less percentage of ICS utilization expressed by a lower ISD/HSD ratio. This ICS utilization is a key issue of medical quality for stroke care.

Variation in Do-Not-Resuscitate Orders and Implications for Heart Failure Risk-Adjusted Hospital Mortality Metrics

ObjectivesThis study evaluated the effect of patient do-not-resuscitate (DNR) status on hospital risk-adjusted heart failure mortality metrics. BackgroundDo-not-resuscitate orders limit the use of life-sustaining therapies. Patients with DNR orders have increased in-hospital mortality, and DNR rates vary among hospitals. Variations in DNR rates could strongly confound risk-adjusted hospital mortality rates for heart failure. MethodsWe identified a cohort of adults with primary diagnosis of heart failure by using the 2011 California State Inpatient Database, a claims database that captures “early DNR,” within 24 h of admission. Hospital-level risk-standardized in-hospital mortality was determined using random effects logistic regression. We explored changes in outlier status in models with and without early DNR status. ResultsAmong 55,865 patients from 290 hospitals hospitalized with heart failure, 12.1% (11.8% to 12.4%) had an early DNR order. Hospitals with higher risk-standardized DNR rates had higher risk-standardized mortality (ρ = 0.241; 95% confidence interval [CI]: 0.129 to 0.346; p < 0.001). Including DNR in models used to benchmark hospital mortality improved model performance (c-statistic from 0.821 [95% CI: 0.812 to 0.830] to 0.845 [95% CI: 0.837 to 0.853]; increased model explanatory power by 17%). Including DNR resulted in reclassification of 9.3% of hospitals’ outlier status. Agreement in hospital outlier designation between models with and without DNR was low to moderate (kappa coefficient: 0.492; 95% CI: 0.331 to 0.654). ConclusionsAccounting for DNR status resulted in a change in estimated risk-standardized mortality rates and classification of hospitals as performance “outliers.” Given public reporting of heart failure mortality measurements and their influence on reimbursement, accounting for the presence of early DNR orders in quality measures should be considered.

Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest

Current guidelines recommend deferring prognostication for 48 to 72 hours after resuscitation from inhospital cardiac arrest. It is unknown whether hospitals vary in making patients who survive an arrest Do-Not-Resuscitate (DNR) early after resuscitation and whether a hospital's rate of early DNR is associated with its rate of favorable neurological survival. Within Get With the Guidelines-Resuscitation, we identified 24,899 patients from 236 hospitals who achieved return of spontaneous circulation (ROSC) after inhospital cardiac arrest between 2006 and 2012. Hierarchical models were constructed to derive risk-adjusted hospital rates of DNR status adoption ≤12 hours after ROSC and risk-standardized rates of favorable neurological survival (without severe disability; Cerebral Performance Category ≤2). The association between hospitals' rates of early DNR and favorable neurological survival was evaluated using correlation statistics. Of 236 hospitals, 61.7% were academic, 83% had ≥200 beds, and 94% were urban. Overall, 5577 (22.4%) patients were made DNR ≤12 hours after ROSC. Risk-adjusted hospital rates of early DNR varied widely (7.1%-40.5%, median: 22.7% [IQR: 19.3%-26.1%]; median OR of 1.48). Significant hospital variation existed in risk-standardized rates of favorable neurological survival (3.5%-44.8%, median: 25.3% [IQR: 20.2%-29.4%]; median OR 1.72). Hospitals' risk-adjusted rates of early DNR were inversely correlated with their risk-standardized rates of favorable neurological survival (r=-0.179, P=.006). Despite current guideline recommendations, many patients with inhospital cardiac arrest are made DNR within 12 hours after ROSC, and hospitals vary widely in rates of early DNR. Higher hospital rates of early DNR were associated with worse meaningful survival outcomes.

Association of Early Do-Not-Resuscitate Orders with Unplanned Readmissions among Patients Hospitalized for Pneumonia.

In the United States, approximately 20% of patients hospitalized with pneumonia are readmitted to a hospital within 30 days. Given the significant costs and healthcare system use resulting from unplanned readmissions, pneumonia readmission rates are a target of national quality measures. Patient do-not-resuscitate (DNR) status strongly influences hospital pneumonia mortality measures; however, associations between DNR status and 30-day readmissions after pneumonia are unclear. Determine the effect of accounting for patient DNR status on hospital readmission measures for pneumonia. After excluding patients with missing data, those who died during the index hospitalization, those who were discharged against medical advice, those who did not reside in California, and those admitted to low pneumonia case-volume hospitals, we identified 30-day unplanned readmissions after an index pneumonia hospitalization from the 2011 California State Inpatient Database. We used hierarchical logistic regression to determine the association between early DNR status (within 24 hours of admission) and 30-day readmission and hospital risk-adjusted readmission rates. We identified 68,691 hospitalizations for pneumonia across 321 hospitals. Patients with early DNR orders were less likely to be readmitted within 30 days (20.0% vs. 22.5%, adjusted odds ratio [aOR], 0.93; 95% confidence interval [CI], 0.88-0.99). Patients with pneumonia admitted to high-versus-low DNR rate hospitals were at lower risk for readmission (DNR rate quartile 4 vs. quartile 1, aOR, 0.62; 95% CI, 0.55-0.70), regardless of individual DNR status. Higher hospital risk-adjusted DNR rates were strongly associated with lower risk-adjusted readmission rates (r = -0.44; P < 0.0001). Inclusion of early DNR status in risk-adjusted readmission models changed ranking categories for 7/321 (2.2%) hospitals, with 2 hospitals no longer labeled as "under-performing outliers." Patients with an early DNR order have a lower risk for readmission after a pneumonia hospitalization. Unmeasured DNR status weakly confounds hospital readmission measures; accounting for patient DNR status would alter readmission ratings for a small number of hospitals.

Provider and Patient Gender Influence on Timing of Do-Not-Resuscitate Orders in Hospitalized Patients with Cancer.

End-of-life decisions and advance directives require timely physician-patient discussions but barriers exist to these discussions. To evaluate the influence of physician and patient gender on the timing of inpatient do-not-resuscitate (DNR) orders. Retrospective cohort study. All adult patients (≥18 years) with cancer who received inpatient DNR orders at The University of Texas MD Anderson Cancer Center between January 2011 and December 2013. Gender interaction between physicians and patients towards timing of the DNR order. We identified 4,157 unique patients with a cancer diagnosis. These patients were treated by 353 physicians, of whom 123 (34.8%) were females and 230 (65.2%) were males. Multivariate analysis showed female patients were 1.3 times more likely to have early DNR orders written during hospital admission than were male patients (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.07-1.50). When comparing gender interaction between physicians and patients, our results showed that female physicians were 1.5 times more likely to write early DNR orders with their female patients than for their male patients (OR, 1.48; 95% CI, 1.13-1.94). Same gender physician-patient dyads were not found between male physician and their patients (OR, 1.09; 95% CI, 0.91-1.31). Higher age, more comorbid conditions, and progression of diseases were also associated with early DNR orders (all p < 0.01). Female patients are more likely to receive early DNR orders from their female physicians. Gender and gender interaction between physician and patients may potentially influence the timing of receiving DNR order.

Association of Do-Not-Resuscitate Orders and Hospital Mortality Rate Among Patients With Pneumonia.

Hospital quality measures that do not account for patient do-not-resuscitate (DNR) status may penalize hospitals admitting a greater proportion of patients with limits on life-sustaining treatments. To evaluate the effect of analytic approaches accounting for DNR status on risk-adjusted hospital mortality rates and performance rankings. A retrospective, population-based cohort study was conducted among adults hospitalized with pneumonia in 303 California hospitals between January 1 and December 31, 2011. We used hierarchical logistic regression to determine associations between patient DNR status, hospital-level DNR rates, and mortality measures. Changes in hospital risk-adjusted mortality rates after accounting for patient DNR status and interhospital variation in the association between DNR status and mortality were examined. Data analysis was conducted from January 16 to September 16, 2015. Early DNR status (within 24 hours of admission). In-hospital mortality, determined using hierarchical logistic regression. A total of 90,644 pneumonia cases (5.4% of admissions) were identified among the 303 California hospitals evaluated during 2011; mean (SD) age of the patients was 72.5 (13.7) years, 51.5% were women, and 59.3% were white. Hospital DNR rates varied (median, 15.8%; 25th-75th percentile, 8.9%-22.3%). Without accounting for patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality (adjusted odds ratio [OR] for highest-quartile DNR rate vs lowest quartile, 1.17; 95% CI, 1.04-1.32), corresponding to worse hospital mortality rankings. In contrast, after accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, hospitals with higher DNR rates had lower mortality (adjusted OR for highest-quartile DNR rate vs lowest quartile, 0.79; 95% CI, 0.70-0.89), with reversal of associations between hospital mortality rankings and DNR rates. Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment. Hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia (r = 0.11; P = .052); however, DNR rates were positively correlated with patient satisfaction scores (r = 0.35; P < .001). Failure to account for DNR status may confound the evaluation of hospital quality using mortality outcomes, penalizing hospitals that admit a greater proportion of patients with limits on life-sustaining treatments. Stakeholders should seek to improve methods to standardize and report DNR status in hospital discharge records to allow further assessment of implications of adjusting for DNR in quality measures.

Full medical support for intracerebral hemorrhage.

This study tested the hypothesis that patients without placement of new do-not-resuscitate (DNR) orders during the first 5 days after intracerebral hemorrhage (ICH) have lower 30-day mortality than predicted by the ICH Score without an increase in severe disability at 90 days. This was a prospective, multicenter, observational cohort study at 4 academic medical centers and one community hospital. Adults (18 years or older) with nontraumatic spontaneous ICH, Glasgow Coma Scale score of 12 or less, who did not have preexisting DNR orders were included. One hundred nine subjects were enrolled. Mean age was 62 years; median Glasgow Coma Scale score was 7, and mean hematoma volume was 39 cm(3). Based on ICH Score prediction, the expected overall 30-day mortality rate was 50%. Observed mortality was substantially lower at 20.2%, absolute average difference 29.8% (95% confidence interval: 21.5%-37.7%). At 90 days, 27.1% had died, 21.5% had a modified Rankin Scale score = 5 (severe disability). A good outcome (modified Rankin Scale score 0-3) was achieved by 29.9% and an additional 21.5% fell into the moderately severe disability range (modified Rankin Scale score = 4). Avoidance of early DNR orders along with guideline concordant ICH care results in substantially lower mortality than predicted. The observed functional outcomes in this study provide clinicians and families with data to determine the appropriate goals of treatment based on patients' wishes.

Do Not Resuscitate Orders for Patients with Intracerebral Hemorrhage: Experience from a Chinese Tertiary Care Center

Aim: This study aimed to determine the frequency and determinant factors of do not resuscitate (DNR) orders in patients with intracerebral hemorrhage (ICH) at a university hospital in China. Methods: Data collected from June 2010 to December 2012 for patients with ICH were retrospectively reviewed. The characteristics and care of patients with and without DNR orders and those with early (≤24 h) and late (>24 h) DNR establishment were compared. Results: Formal DNR orders were filed during hospitalization for 64/759 (8.4%) patients with complete medical records enrolled in this study. Patients with DNR orders were older on average (73.1 ± 10.1 vs. 56.0 ± 13.2 years; p < 0.001) and a larger proportion had pre-ICH comorbidity impacting dependency (87.5 vs. 17.0%; p < 0.001) than did those with no DNR order. Patients with DNR orders were in worse clinical condition on arrival than those without a DNR order, as judged by Glasgow Coma Scale scores, and more frequently had large hematoma volumes (78.1 vs. 39.7%; p < 0.001). Conclusions: DNR orders were not used commonly for patients with ICH in this Chinese sample. No relationship between ICH severity and DNR decision making was observed.

Patient and hospital-level characteristics associated with the use of do-not-resuscitate orders in patients hospitalized for sepsis.

Identifying factors associated with do-not-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed. A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders. Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order. Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .

Variation in Do-Not-Resuscitate Orders for Patients With Ischemic Stroke

Background and Purpose— Decisions on life-sustaining treatments and the use of do-not-resuscitate (DNR) orders can affect early mortality after stroke. We investigated the variation in early DNR use after stroke among hospitals in California and the effect of this variation on mortality-based hospital classifications. Methods— Using the California State Inpatient Database from 2005 to 2011, ischemic stroke admissions for patients aged ≥50 years were identified. Cases were categorized by the presence or the absence of DNR orders within the first 24 hours of admission. Multilevel logistic regression models with a random hospital intercept were used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors, and demographics. Hospital mortality rank order was assigned based on this model and compared with the results of a second model that included DNR status. Results— From 355 hospitals, 252 368 cases were identified, including 33 672 (13.3%) with early DNR. Hospital-level–adjusted use of DNR varied widely (quintile 1, 2.2% versus quintile 5, 23.2%). Hospitals with higher early DNR use had higher inpatient mortality because inpatient mortality more than doubled from quintile 1 (4.2%) to quintile 5 (8.7%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum, including among high mortality hospitals. Conclusions— There is wide variation in the hospital-level proportion of ischemic stroke patients with early DNR orders; this variation affects hospital mortality estimates. Unless the circumstances of early DNR orders are better understood, mortality-based hospital comparisons may not reliably identify hospitals providing a lower quality of care.

Abstract 19: Hospital Level Variation in Do-Not-Resuscitate Orders for Ischemic Stroke Patients: Implications for National Hospital Comparisons

Background: The Center for Medicare and Medicaid Services (CMS) plans to publicly report hospital-level adjusted ischemic stroke mortality as a marker of hospital quality. Do-not-resuscitate (DNR) orders, which are a well-known predictor of mortality after stroke, are not accounted for in the current CMS risk-adjustment model. Methods: Using the California State Inpatient Database from 2005-2011, ischemic stroke admissions (primary ICD-9 codes 433.x1, 434.x1, 436) over age 50 were identified. Cases were categorized by the presence/absence of a DNR order within the first 24 hours of admission. Multi-level logistic regression with a random hospital intercept was used to predict inpatient mortality after adjusting for comorbidities, vascular risk factors and demographics. Hospital mortality rank order was assigned based on this model and compared to the results of a second model that included DNR status. Results: From 356 hospitals, 261,921 cases were identified: 34,436 with early DNR (13.1%) and 227,485 without (86.9%). 43.1% of all mortality occurred in patients with DNR orders. Hospital-level utilization of DNR varied widely (quintile 1, 2.5% vs. quintile 5, 30.7%; p &lt; 0.001). Compared to a model with DNR, a model not accounting for DNR overestimated mortality by at least 1% (absolute) in 36 hospitals (maximum change 2.4%) and underestimated mortality by at least 1% (absolute) in 15 hospitals (maximum change 1.8%). Failure to adjust for DNR orders resulted in substantial hospital reclassification across the rank spectrum (Figure). Conclusions: There is wide variation in the hospital-level proportion of ischemic stroke patients with DNR orders. To the extent variation in hospital-level DNR orders represents variation in patient preferences, CMS risk-adjusted mortality measures may result in hospital misclassification, and specifically punish hospitals treating a high proportion of patients who prefer lower intensity treatment.

Abstract T MP73: Effect of Hospital Factors on Individual-Level Early Do-Not-Resuscitate Orders in Ischemic Stroke

Background: Race-ethnic (R/E) minorities are less likely to have Do-Not-Resuscitate (DNR) orders than non-Hispanic whites. Since race and ethnicity cluster by hospital, institutional factors may contribute to this variability in DNR orders. We investigated the influence of hospital-level proportion of R/E minorities on R/E differences in individual-level DNR decisions. Methods: Cases of ischemic stroke were identified from the California State Inpatient Database (age &gt;=50, 2005-2011, ICD-9 codes 433.x1, 434.x1, 436 in primary position). Hospitals were classified by the proportion of R/E minority (Black or Hispanic) patients seen at each institution (reported as quartiles). Individual-level early DNR orders (within 24 hours) were reported by individual-level race-ethnicity (White, Asian, Hispanic, or Black), stratified by hospital-level proportion of R/E minority (Black or Hispanic) patients using multilevel logistic regression with a random hospital intercept. Results: A total of 259,953 cases of ischemic stroke across 370 hospitals were included (Mean age 74, Female 53%, White 59%, Black 8.8%, Hispanic 17%, Asian 8.9%, Others 6.0%). There was variability in the proportion of R/E minority patients seen at the hospital level (Black: range 0-82%, median 2.3%; Hispanic: range 0-96%, median 12.2%). Increasing hospital-level proportion of minority patients seen was associated with less use of DNR orders across all R/E groups. Similar effects were seen when stratified by hospital-level quartile of Black (Figure “A”) or Hispanic (Figure “B”) patients (p&lt;0.001 for both). White patients with ischemic stroke admitted to hospitals that cared for more minority patients used early DNR orders at a frequency similar to R/E minorities. Conclusions: The probability of an early DNR order after ischemic stroke is due not only to different treatment patterns across R/E groups, but also to differential treatment patterns at hospitals that care for more R/E minorities.

Sex Differences in the Use of Early Do-Not-Resuscitate Orders After Intracerebral Hemorrhage

Studies show that women are more likely to receive do-not-resuscitate (DNR) orders after acute medical illnesses than men. However, the sex differences in the use of DNR orders after acute intracerebral hemorrhage (ICH) have not been described. We conducted a retrospective study of consecutive patients hospitalized for acute ICH at a tertiary stroke center between 2006 and 2010. Unadjusted and multivariable logistic regression analyses were performed to test for associations between female sex and early (<24 hours of presentation) DNR orders. A total of 372 consecutive ICH patients without preexisting DNR orders were studied. Overall, 82 (22%) patients had early DNR orders after being hospitalized with ICH. In the fully adjusted model, early DNR orders were more likely in women (odds ratio, 3.18; 95% confidence interval, 1.51-6.70), higher age (odds ratio, 1.09 per year; 95% confidence interval, 1.05-1.12), larger ICH volume (odds ratio, 1.01 per cm(3); 95% confidence interval, 1.01-1.02), and lower initial GCS score (odds ratio, 0.76 per point; 95% confidence interval, 0.69-0.84). Early DNR orders were less likely when the patients were transferred from another hospital (odds ratio, 0.28, 95% confidence interval, 0.11-0.76). Women are more likely to receive early DNR orders after ICH than men. Further prospective studies are needed to determine factors contributing to the sex variation in the use of early DNR order after ICH.

Is Early DNR a Self-Fulfilling Prophecy for Patients with Spontaneous Intracerebral Hemorrhage?

To investigate differences in outcome of patients with intracerebral hemorrhage (ICH) based on institution of do-not-resuscitate (DNR) order within first 24 h of admission. A prospective registry of patients presenting with ICH from Jan 2006 to Dec 2008 was created. Patients with and without DNR orders instituted within 24 h of admission were classified as cases and controls respectively and were matched based on age and stroke severity. Demographics, intracerebral volume of hematoma, intraventricular extension of hemorrhage (IVH), invasive treatments, and outcomes at discharge were collected. All patients were followed up at least for 1 year, to determine mortality outcomes. Of a total of 245 subjects, 18 % had DNR order instituted within 24 h of admission. After matching, a total of 69 controls were available for 44 cases. There was no difference in demographics, IVH extension, volume of hemorrhage, and length of stay among cases and controls. Higher proportions of controls had surgical evacuation of the hematoma (p = 0.0125) and mechanical ventilation (p = 0.0001). There was no significant difference in functional outcome and survival rates among cases and controls at the end of 1 week, 1 month, and 1 year. DNR institution and restriction of resuscitation was not associated with poor outcome or difference in survival within 1 year after ICH. This indicates an early DNR probably does not lead to a self-fulfilling prophecy in this population, and might be explained by our practice, were DNR orders do not impact the level of supportive medical care we provide.

Abstract TP303: Gender Differences in the Use of Early Do-Not-Resuscitate Orders after Intracerebral Hemorrhage

Background and Purpose: Studies show that women are more likely to receive do-not-resuscitate (DNR) orders after acute medical illnesses than men. However, the gender differences in the use of early (&lt;24 hours of presentation) DNR order after acute intracerebral hemorrhage (ICH) has not been described. Methods: We conducted a retrospective study of consecutive patients hospitalized for acute ICH at a tertiary stroke center between 2006 and 2010. Unadjusted and multivariable logistic regression analyses were used to test for associations between female gender and early DNR orders (&lt;24 hours of presentation). Results: A total of 373 consecutive ICH patients without pre-existing DNR orders (NHPI 19%, Asians 62%, non-Hispanic whites 15% and other 4%) were studied. Unadjusted analysis showed that women were more likely to receive early DNR orders compared to men (odds ratio 2.26, 95% CI 1.37 to 3.72). In the fully adjusted model, the independent predictors of early DNR orders were female gender (odds ratio 3.21, 95% CI 1.52 to 6.78), age (odds ratio 1.08 per year, 95% CI 1.05 to 1.11), ICH volume (odds ratio 1.02 per cm3, 95% CI 1.01 to 1.03), initial GCS score (odds ratio 0.74 per point, 95% CI 0.66 to 0.82) and whether the patient was transferred from another hospital (odds ratio 0.28, 95% 0.11 to 0.76). When comparing gender-related outcome, mortality was not different between women and men (25% vs. 27%, p = 0.71). Conclusions: Women are more likely to receive early DNR orders after ICH than men. Further prospective study is needed to determine factors contributing to the gender variation in the use of early DNR order after ICH and whether this variation represents differences in patient preferences or preferences of the surrogate decision-makers.

The impact of early do not resuscitate (DNR) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest

ObjectivesAmong patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) and admitted to California hospitals, we examined how the placement of a do not resuscitate (DNR) order in the first 24h after admission was associated with patient care, procedures and inhospital survival. We further analyzed hospital and patient demographic factors associated with early DNR placement among patients admitted following OHCA. MethodsWe identified post-OHCA patients from a statewide California database of hospital admissions from 2002 to 2010. Documentation of patient and hospital demographics, hospital interventions, and patient outcome were analyzed by descriptive statistics and multiple regression models to calculate odds ratios and 95% confidence intervals. ResultsOf 5212 patients admitted to California hospitals after resuscitation from OHCA, 1692 (32.5%) had a DNR order placed in the first 24h after admission. These patients had decreased frequency of cardiac catheterization (1.1% vs. 4.3%), blood transfusion (7.6% vs. 11.2%), ICD placement (0.1% vs. 1.1%), and survival to discharge (5.2% vs. 21.6%, all p-values<0.0001). There was wide intrahospital variability and significant racial differences in the adjusted odds of early DNR orders (Asian, OR 0.67, 95% CI 0.48–0.95; Black, OR 0.49, 95% CI 0.35–0.69). ConclusionsEarly DNR placement is associated with a decrease in potentially critical hospital interventions, procedures, and survival to discharge, and wide variability in practice patterns between hospitals. In the absence of prior patient wishes, DNR placement within 24h may be premature given the lack of early prognostic indicators after OHCA.

Do-not-resuscitate orders and predictive models after intracerebral hemorrhage

# {#article-title-2} To the Editor: Zahuranec et al.1 outline the impact of early do-not-resuscitate (DNR) orders on the accuracy of intracerebral hemorrhage (ICH) predictive models. The authors found that the ICH Score,2 Cincinnati model,3 and ICH grading scale (ICH-GS)4 underestimated mortality in patients with early DNR orders by 18.7%,2 26.3%,3 and 5.7%4 compared to the observed rate of 83.5%. The models overestimated mortality in those without DNR orders by 5.8%,2 10.6%,3 and 20.3%4 …