The effect of do-not-resuscitate orders on physician decision-making

Do-not-attempt-resuscitation (DNAR) orders: understanding and interpretation of their use in the hospitalised patient in Ireland. A brief report

Following the introduction of do-not-resuscitate (DNR) orders in the 1970s, there was widespread misinterpretation of the term among healthcare professionals. In this brief report, we present findings from a survey of healthcare professionals. Our aim was to examine current understanding of the term do-not-attempt-resuscitate (DNAR), decision-making surrounding DNAR and awareness of current guidelines. The survey was distributed to doctors and nurses in a university teaching hospital and affiliated primary care physicians in Dublin via email and by hard copy at educational meetings from July to December 2014. A total of 519 completed the survey. The response rate in the hospital doctors group was 35.5% (187/527), 19.8% (292/1477) in the nurses group but 68.8% (150/218) in the specialist nurses group and 40% (40/100) in the primary care physician group.Alarmingly, our results demonstrate that 26.8% of staff nurses and 30% of primary care physicians surveyed believed that a patient with a DNAR order could not receive any/at least one of a list of simple treatments including antibiotics, physiotherapy, intravenous fluids, pain relief, oxygen, nasogastric feeding or airway suctioning, which were higher percentages compared to the other hospital doctors and experienced nurses groups with statistically significant differences (p<0.001). Furthermore, a higher percentage of staff nurses (26.8%) and primary care physicians (22.5%) believed that a patient with a DNAR order could not be referred to hospital from home/a nursing home, when compared with other healthcare groups (p<0.001). Our findings highlight continued misunderstanding and over-interpretation of DNAR orders. Further collaboration and information is required for meaningful Advance Care Plans.

Association between Do Not Resuscitate/Do Not Intubate Status and Resident Physician Decision-making. A National Survey

RATIONALE

Compared with their Full Code counterparts, patients with do not resuscitate/do not intubate (DNR/DNI) status receive fewer interventions and have higher mortality than predicted by clinical characteristics.

OBJECTIVES

To assess whether internal medicine residents, the front-line providers for many hospitalized patients, would manage hypothetical patients differently based on code status. We hypothesized respondents would be less likely to provide a variety of interventions to DNR/DNI patients than to Full Code patients.

METHODS

Cross-sectional, randomized survey of U.S. internal medicine residents. We created two versions of an internet survey, each containing four clinical vignettes followed by questions regarding possible interventions; the versions were identical except for varying code status of the vignettes. Residency programs were randomly allocated between the two versions.

RESULTS

Five hundred thirty-three residents responded to the survey. As determined by Chi-squared and Fisher's exact test, decisions to intubate or perform cardiopulmonary resuscitation were largely dictated by patient code status (>94% if Full Code, <5% if DNR/DNI; P < 0.0001 for all scenarios). Resident proclivity to deliver noninvasive interventions (e.g., blood cultures, medications, imaging) was uniformly high (>90%) and unaffected by code status. However, decisions to pursue other aggressive or invasive options (e.g., dialysis, bronchoscopy, surgical consultation, transfer to intensive care unit) differed significantly based on code status in most vignettes.

CONCLUSIONS

Residents appear to assume that patients who would refuse cardiopulmonary resuscitation would prefer not to receive other interventions. Without explicit clarification of the patient's goals of care, potentially beneficial care may be withheld against the patient's wishes.

‘Do not resuscitate’ decisions in continuing care psychiatric patients: what influences decisions?

Aims and Method

We evaluated the various aspects of ‘do not resuscitate’ (DNR) decisions taken for psychiatric continuing care patients within NHS Ayrshire and Arran. Records were reviewed and nursing staff were asked their opinions about DNR orders in general and the way these were implemented on their wards.

Results

There were 35 DNR orders among 88 continuing care patients in mental health wards for older adults. There were no DNR orders for the 25 continuing care patients in general adult psychiatry wards. Quality of life was the main issue when taking a DNR decision. Medical and nursing staff were involved in all decisions and the family in most. Patients were involved in only two cases. The documentation of the DNR order itself was satisfactory but documentation of the reasons behind the decision was inadequate. Patients with DNR status were perceived by ward staff to have more physical debilitation and more dependence on others. Local guidelines were being followed in most aspects, but these needed to be reviewed, as suggested within the resuscitation policy itself.

Clinical Implications

Decisions not to resuscitate may often be difficult to reach in psychiatric patients. Wards follow heterogeneous policies despite a resuscitation policy existing within the trust. Documentation needs to be improved and medical and nursing staff must reach a consensus regarding what constitutes quality of life and the appropriate time for a DNR decision.

Knowledge and Attitude of ER and Intensive Care Unit Physicians toward Do-Not-Resuscitate in a Tertiary Care Center in Saudi Arabia: A Survey Study

Introduction

Only a few studies from Arab Muslim countries address do-not-resuscitate (DNR) practice. The knowledge of physicians about the existing policy and the attitude towards DNR were surveyed.

Objective

The objective of this study is to identify the knowledge of the participants of the local DNR policy and barriers of addressing DNR including religious background.

Methods

A questionnaire has been distributed to Emergency Room (ER) and Intensive Care Unit (ICU) physicians.

Results

A total of 112 physicians mostly Muslims (97.3%). About 108 (96.4%) were aware about the existence of DNR policy in our institute. 107 (95.5%) stated that DNR is not against Islamic. Only (13.4%) of the physicians have advance directives and (90.2%) answered they will request to be DNR if they have terminal illness. Lack of patients and families understanding (51.8%) and inadequate training (35.7%) were the two most important barriers for effective DNR discussion. Patients and families level of education (58.0%) and cultural factors (52.7%) were the main obstacles in initiating a DNR order.

Conclusions

There is a lack of knowledge about DNR policy which makes the optimization of DNR process difficult. Most physicians wish DNR for themselves and their patients at the end of life, but only a few of them have advance directives. The most important barriers for initializing and discussing DNR were lack of patient understanding, level of education, and the culture of patients. Most of the Muslim physicians believe that DNR is not against Islamic rules. We suggest that the DNR concept should be a part of any training program.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Do-not-resuscitate orders and early mortality in hip fracture patients

Background

factors affecting mortality after hip fracture surgery have been studied extensively. It has been suggested that do-not-resuscitate (DNR) orders are associated with higher mortality in surgical patients due to less aggressive treatment. However, the effect of DNR orders on mortality in hip fracture patients is unknown. The objective of this study was to investigate the effect of DNR orders on early mortality after hip fracture surgery.

Methods

all patients undergoing hip fracture surgery between 2004 and 2015 were included in this retrospective study. Patient characteristics such as age, comorbidities and fracture type were collected, as were resuscitation preferences. Multivariable logistic regression analysis was performed to identify independent risk factors for early mortality.

Results

a total of 1,803 patients were analysed, of which 823 (45.6%) had DNR orders. DNR patients were older, more often female, had lower haemoglobin levels and more comorbidities when compared with non-DNR patients. The unadjusted effect of DNR orders on mortality was high (OR: 2.39; P < 0.001). Multivariable analysis demonstrated that increased age, male gender, higher American Society of Anesthesiologists score, low admission haemoglobin, living in an institution, high Charlson Comorbidity Index and delay to surgery were associated with increased early mortality after hip fracture surgery. There was no independent effect of DNR orders on mortality after adjustment for these variables (P = 0.735).

Conclusions

DNR patients have higher mortality rates due to poor health status. Resuscitation preferences on their own are not associated with early mortality after hip fracture surgery.

Do-Not-Resuscitate Status Is Associated With Increased Mortality But Not Morbidity

BACKGROUND

Do-not-resuscitate (DNR) orders instruct medical personnel to forego cardiopulmonary resuscitation in the event of cardiopulmonary arrest, but they do not preclude surgical management. Several studies have reported that DNR status is an independent predictor of 30-day mortality; however, the etiology of increased mortality remains unclear. We hypothesized that DNR patients would demonstrate increased postoperative mortality, but not morbidity, relative to non-DNR patients undergoing the same procedures.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database for 2007-2013, we performed a retrospective analysis to compare DNR and non-DNR cohorts matched by the most common procedures performed in DNR patients. We employed univariable and multivariable logistic regression to characterize patterns of care in the perioperative period as well as identify independent risk factors for increased mortality and assess for the presence of "failure to rescue."

RESULTS

The most common procedures performed on DNR patients were emergent and centered on immediate symptom relief. When adjusting for preoperative factors, DNR patients were still found to have increased incidence of postoperative mortality (odds ratio 2.54 [2.29-2.82], P < .001) but not postoperative morbidity at 30 days. In addition, cardiopulmonary resuscitative measures and unplanned intubation were found to be less frequent in the DNR cohort.

CONCLUSIONS

These findings suggest that increased mortality is the result of adherence to goals of care rather than "failure to rescue."

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

OBJECTIVES

This study evaluated the effect of patient do-not-resuscitate (DNR) status on hospital risk-adjusted heart failure mortality metrics.

BACKGROUND

Do-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.

METHODS

We 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.

RESULTS

Among 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).

CONCLUSIONS

Accounting 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.

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU

OBJECTIVES

We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs.

DESIGN

Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008.

INTERVENTION

None.

PATIENTS

Two cohorts were defined: patients with do not resuscitate advance directives on day 1 of ICU admission and a control group comprising patients with no limitations of level of care on ICU day 1 (full code).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was mortality at 28 days after ICU admission. Of 19,007 ICU patients, 1,239 patients (6.5%) had a do-not-resuscitate order on the first day of ICU admission and survived 48 hours in the ICU. We matched those do-not-resuscitate patients with 2,402 patients with full-code status. Twenty-eight day and 1-year mortality were both significantly higher in the do-not-resuscitate group (33.9% vs 18.4% and 60.7% vs 40.2%; p < 0.001, respectively).

CONCLUSION

Do-not-resuscitate status is an independent risk factor for ICU mortality. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status.

TRIAD IV: Nationwide Survey of Medical Students' Understanding of Living Wills and DNR Orders

INTRODUCTION

Living wills are a form of advance directives that help to protect patient autonomy. They are frequently encountered in the conduct of medicine. Because of their impact on care, it is important to understand the adequacy of current medical school training in the preparation of physicians to interpret these directives.

METHODS

Between April and August 2011 of third and fourth year medical students participated in an internet survey involving the interpretation of living wills. The survey presented a standard living will as a "stand-alone," a standard living will with the addition an emergent clinical scenario and then variations of the standard living will that included a code status designation ("DNR," "Full Code," or "Comfort Care"). For each version/ scenario, respondents were asked to assign a code status and choose interventions based on the cases presented.

RESULTS

Four hundred twenty-five students from medical schools throughout the country responded. The majority indicated they had received some form of advance directive training and understood the concept of code status and the term "DNR." Based on a stand-alone document, 15% of respondents correctly denoted "full code" as the appropriate code status; adding a clinical scenario yielded negligible improvement. When a code designation was added to the living will, correct code status responses ranged from 68% to 93%, whereas correct treatment decisions ranged from 18% to 78%. Previous training in advance directives had no impact on these results.

CONCLUSION

Our data indicate that the majority of students failed to understand the key elements of a living will; adding a code status designations improved correct responses with the exception of the term DNR. Misunderstanding of advance directives is a nationwide problem and jeopardizes patient safety. Medical School ethics curricula need to be improved to ensure competency with respect to understanding advance directives.

Levels of Intervention: How Are They Used in Quebec Hospitals?

In order to promote better practices and communication around end-of-life decision-making, several Canadian hospitals in the province of Quebec have developed a tool called "Levels of Intervention" (LOI). No work to date has been published demonstrating improvement since these forms were implemented. The purpose of the present study was to obtain information about the use of LOI forms across Quebec hospitals and to identify gaps in practice as well as areas for improvement. A retrospective study was undertaken of 299 charts of patients who had died in three Quebec hospitals with a LOI ordered. Results were analysed through a principlism ethical framework. High compliance with the level of intervention ordered at the time of death was recorded, as well as high involvement of patient and/or family, demonstrating the efficiency of LOI in promoting respect for autonomy. Other results show delays in end-of-life care discussions in the course of the hospitalization. Only a small proportion of patients who died had a palliative care consultation, which may reflect equity issues in access to care. This study highlights the importance of the LOI in Quebec and the role it is playing in respect for end-of-life preferences as well as in the involvement of patients and families in the decision-making process. Training specific to end-of-life decision-making conversations would help support the LOI form's use, as would developing provincial or national guidelines on the use of LOI to standardize organizational policies and practice around end-of-life care.

Resuscitation policy should focus on the patient, not the decision

Zoë Fritz and colleagues discuss new approaches to resuscitation decisions that incorporate broader goals of care

Hospital Variation in Utilization of Life-Sustaining Treatments among Patients with Do Not Resuscitate Orders

OBJECTIVE

To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders.

DATA SOURCES/SETTING

United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database.

STUDY DESIGN

Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital "early" DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions.

DATA COLLECTION/EXTRACTION METHODS

California State Inpatient Database, year 2011.

PRINCIPAL FINDINGS

Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates.

CONCLUSIONS

Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders.

The Use of Advance Care Planning to Guide Decisions About Artificial Nutrition and Hydration

Advance care planning is important to ensure that patients, when competent, can influence the kind of medical care they receive if they lose decision-making capacity. Because decisions by surrogates to for-go nutrition support remain controversial, specific inclusion of artificial nutrition and hydration as a part of advance care planning has taken on growing importance. This article reviews the choices about artificial nutrition and hydration that are possible using conventional advance directives such as the living will, the instructional directive, values histories, and combination directives. It summarizes the legal basis for such documents. It also describes the ways that physicians' orders to limit treatment can help implement decisions about the use of artificial nutrition and hydration. Finally, it stresses the importance of clarifying with patients and families the risks and benefits of nutrition support in a variety of common situations such as advanced dementia and metastatic cancer as an essential prerequisite to meaningful advance care planning.

Does resuscitation status affect decision making in a deteriorating patient? Results from a randomised vignette study

AIMS AND OBJECTIVES

The aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options ('UFTO': an alternative approach that contextualizes the resuscitation decision within an overall treatment plan) on nurses' decision making about a deteriorating patient.

METHODS

An online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no-form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures.

RESULTS

Reported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no-form groups (P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments (all P < 0.001). There was no difference between the UFTO and no-form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups.

CONCLUSION

The presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no-form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care.

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes

As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

A Comparison of Circumstances at the End of Life in a Hospital Setting for Children With Palliative Care Involvement Versus Those Without

CONTEXT

Specialized pediatric palliative care (PPC) services have become more common in urban pediatric hospital settings, although little is known about palliative care specialist involvement.

OBJECTIVES

The objective of this study was to compare circumstances before death in children who spent their last days of life in an inpatient pediatric hospital setting, with or without PPC provider involvement during their inpatient stay.

METHODS

Retrospective chart review of medical records of children for the last inpatient stay that resulted in death at a children's hospital setting between January 2012 through June 2013. The setting was a free-standing, 385-bed tertiary care children's hospital.

RESULTS

Charts were reviewed for 114 children between 0 and 18 years of age, who were hospitalized for at least 24 hours before their death. Half of the children who died as inpatients were infants (median age five weeks). Children who received an inpatient PPC consult (25% of the sample) experienced 1) a higher rate of pain assessments, 2) better documentation around specific actions to manage pain, 3) greater odds of receiving integrative medicine services, 4) fewer diagnostic/monitoring procedures (e.g., blood gases, blood draws, placements of intravenous lines) in the last 48 hours of life, and 5) nearly eight times greater odds of having a do-not-resuscitate order in place at the time of death.

CONCLUSION

The integration of a PPC team was associated with fewer diagnostic/monitoring procedures and improved pain management documentation in this study of 114 children who died as inpatients.

Care Consistency With Documented Care Preferences: Methodologic Considerations for Implementing the "Measuring What Matters" Quality Indicator

A basic tenet of palliative care is discerning patient treatment preferences and then honoring these preferences, reflected by the inclusion of "Care Consistency With Documented Care Preferences" as one of 10 "Measuring What Matters quality" indicators. Measuring What Matters indicators are intended to serve as a foundation for quality measurement in health care settings. However, there are a number of logistic and practical issues to be considered in the application of this quality indicator to clinical practice. In this brief methodologic report, we describe how care consistency with documented care preferences has been measured in research on patients near the end of life. Furthermore, we outline methodologic challenges in using this indicator in both research and practice, such as documentation, specificity and relevance, preference stability, and measuring nonevents. Recommendations to strengthen the accuracy of measurement of this important quality marker in health care settings include consistent recording of preferences in the medical record, considerations for selection of treatment preferences for tracking, establishing a protocol for review of preferences, and adoption of a consistent measurement approach.

Hospital Noninvasive Ventilation Case Volume and Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

RATIONALE

Higher hospital case volume may produce local expertise ("practice makes perfect"), resulting in better patient outcomes. Associations between hospital noninvasive ventilation (NIV) case volume and outcomes for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) are unclear.

OBJECTIVES

To determine associations between total hospital NIV case volume for all indications and NIV failure and hospital mortality among patients with acute exacerbations of COPD.

METHODS

Using the 2011 California State Inpatient Database and multivariable hierarchical logistic regression, we calculated hospital-level risk-adjusted rates for NIV failure (progression from NIV to invasive mechanical ventilation) and hospital mortality among patients with acute exacerbations of COPD.

MEASUREMENTS AND MAIN RESULTS

We identified 37,516 hospitalizations for acute exacerbations of COPD in 252 California hospitals in 2011. Total hospital NIV use for all indications ranged from 2 to 565 cases (median, 64; interquartile range, 96). Hospital NIV failure rates for acute exacerbations of COPD ranged from 3.7 to 31.3% (median, 8.5%; interquartile range, 4.2). At the hospital level, higher total hospital NIV case volume was weakly associated with higher hospital NIV failure rates for acute exacerbations of COPD (r = 0.13; P = 0.03). Higher hospital NIV failure rates were weakly associated with higher hospital mortality rates for acute exacerbations of COPD (r = 0.15; P = 0.02), but higher total hospital NIV case volume was not associated with hospital mortality for exacerbations of COPD (r = -0.11; P = 0.08). At the patient level, patients admitted to high-NIV versus low-NIV case-volume hospitals had greater odds of NIV failure (quartile 4 vs. quartile 1 adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.12-3.40). Compared with initial treatment with invasive mechanical ventilation, NIV failure was associated with higher odds of death (aOR, 1.81; 95% CI, 1.35-2.44). However, admission to high-NIV versus low-NIV case-volume hospitals was not significantly associated with patient in-hospital mortality (quartile 4 vs. quartile 1 aOR, 0.76; 95% CI, 0.57-1.02).

CONCLUSIONS

Despite strong evidence for use of NIV in the management of acute exacerbations of COPD, we observed no significant mortality benefit and higher rates of NIV failure in high-NIV case-volume hospitals. Further investigation of patient selection and hospital factors associated with NIV failure is needed to maximize favorable patient outcomes associated with use of NIV for acute exacerbations of COPD.

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

BACKGROUND

Severe 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.

METHODS

A 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.

RESULTS

Sixty-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.

CONCLUSIONS

From 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.

Clinician Perspectives on Challenges to Patient Centered Care at the End of Life

Discussions regarding patient preferences for resuscitation are often delayed and preferences may be neglected, leading to the receipt of unwanted medical care. To better understand barriers to the expression and realization of patients’ end of life wishes, a preventive ethics team in one Veterans Affairs Medical Center conducted a survey of physicians, nurses, social workers, and respiratory therapists. Surveys were analyzed through qualitative analysis, using sorting methodologies to identify themes. Analysis revealed barriers to patient wishes being identified and followed, including discomfort conducting end-of-life discussions, difficulty locating patients’ preferences in medical records, challenges with expiring do not resuscitate (DNR) orders, and confusion over terminology. Based on these findings, the preventive ethics team proposed new terminology for code status preferences, elimination of the local policy for expiration of DNR orders, and enhanced systems for storing and retrieving patients’ end-of-life preferences. Educational efforts were initiated to facilitate implementation of the proposed changes.

What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

Background

Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures.

Methods

A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated.

Results

We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%).

Conclusion

DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.

Further deliberating the relationship between do-not-resuscitate and the increased risk of death

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.

Outcomes of Cardiopulmonary Resuscitation and Estimation of Healthcare Costs in Potential 'Do Not Resuscitate' Cases

OBJECTIVES

Cardiopulmonary resuscitation (CPR) is a life-saving procedure which may fail if applied unselectively. 'Do not resuscitate' (DNR) policies can help avoid futile life-saving attempts among terminally-ill patients. This study aimed to assess CPR outcomes and estimate healthcare costs in potential DNR cases.

METHODS

This retrospective study was carried out between March and June 2014 and included 50 adult cardiac arrest patients who had undergone CPR at Sultan Qaboos Hospital in Salalah, Oman. Medical records were reviewed and treating teams were consulted to determine DNR eligibility. The outcomes, clinical risk categories and associated healthcare costs of the DNR candidates were assessed.

RESULTS

Two-thirds of the potential DNR candidates were ≥60 years old. Eight patients (16%) were in a vegetative state, 39 (78%) had an irreversible terminal illness and 43 (86%) had a low likelihood of successful CPR. Most patients (72%) met multiple criteria for DNR eligibility. According to clinical risk categories, these patients had terminal malignancies (30%), recent massive strokes (16%), end-stage organ failure (30%) or were bed-bound (50%). Initial CPR was unsuccessful in 30 patients (60%); the remaining 20 patients (40%) were initially resuscitated but subsequently died, with 70% dying within 24 hours. These patients were ventilated for an average of 5.6 days, with four patients (20%) requiring >15 days of ventilation. The average healthcare cost per patient was USD $1,958.9.

CONCLUSION

With careful assessment, potential DNR patients can be identified and futile CPR efforts avoided. Institutional DNR policies may help to reduce healthcare costs and improve services.

The Associations Between the Religious Background, Social Supports, and Do-Not-Resuscitate Orders in Taiwan: An Observational Study

Prior studies have demonstrated important implications related to religiosity and a do-not-resuscitate (DNR) decision. However, the association between patients' religious background and DNR decisions is vague. In particular, the association between the religious background of Buddhism/Daoism and DNR decisions has never been examined. The objective of this study was to examine the association between patients' religious background and their DNR decisions, with a particular focus on Buddhism/Daoism.The medical records of the patients who were admitted to the 3 surgical intensive care units (SICU) in a university-affiliated medical center located at Northern Taiwan from June 1, 2011 to December 31, 2013 were retrospectively collected. We compared the clinical/demographic variables of DNR patients with those of non-DNR patients using the Student t test or χ test depending on the scale of the variables. We used multivariate logistic regression analysis to examine the association between the religious backgrounds and DNR decisions.A sample of 1909 patients was collected: 122 patients had a DNR order; and 1787 patients did not have a DNR order. Old age (P = 0.02), unemployment (P = 0.02), admission diagnosis of "nonoperative, cardiac failure/insufficiency" (P = 0.03), and severe acute illness at SICU admission (P < 0.01) were significantly associated with signing of DNR orders. Patients' religious background of Buddhism/Daoism (P = 0.04), married marital status (P = 0.02), and admission diagnosis of "postoperative, major surgery" (P = 0.02) were less likely to have a DNR order written during their SICU stay. Furthermore, patients with poor social support, as indicated by marital and working status, were more likely to consent to a DNR order during SICU stay.This study showed that the religious background of Buddhism/Daoism was significantly associated with a lower likelihood of consenting to a DNR, and poor social support was significantly associated with a higher likelihood of having a DNR order written during SICU stay.

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

IMPORTANCE

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.

OBJECTIVE

To evaluate the effect of analytic approaches accounting for DNR status on risk-adjusted hospital mortality rates and performance rankings.

DESIGN, SETTING, AND PARTICIPANTS

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.

EXPOSURES

Early DNR status (within 24 hours of admission).

MAIN OUTCOMES AND MEASURES

In-hospital mortality, determined using hierarchical logistic regression.

RESULTS

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).

CONCLUSIONS AND RELEVANCE

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.

Differences and Trends in DNR Among California Inpatients With Heart Failure

BACKGROUND

Do-not-resuscitate (DNR) orders reflect an important means of respecting patient autonomy while minimizing the risk of nonbeneficial interventions. We sought to clarify trends and differences in rates of DNR orders for patients hospitalized with heart failure.

METHODS

We used statewide data from California's Healthcare Cost and Utilization dataset (2007-2010) to determine trends in DNR orders within 24 hours of admission for patients with a primary discharge diagnosis of heart failure.

RESULTS

Among 347,541 hospitalizations for heart failure, the rate of DNR order within 24 hours increased from 10.4% in 2007 to 11.3% in 2010 (P < .0001). After adjustment, DNR status correlated with older age, female gender, white race, frequent comorbidities (Charlson Score), and residence in higher income area (P < .0001). DNR use was more likely in hospitals with public or nonprofit financing or medical school affiliation, but not being a member of the Council on Teaching Hospitals (all P < .001).

CONCLUSION

DNR order use among inpatients with heart failure is low but increasing slowly and varies by patient demographics and hospital characteristics.

Preventing Safety Hazards Associated With Do-Not-Resuscitate Orders

Do-not-resuscitate orders can promote patients' dignity near the end of life, but they also can carry safety hazards associated with miscommunication and inappropriate withdrawal of certain kinds of care. Oncology nurses have a responsibility to identify these potential hazards and to intervene as necessary.
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Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department

PURPOSE

The purpose was to identify risk factors associated with in-hospital mortality among emergency department (ED) patients with severe sepsis and septic shock managed with early protocolized resuscitation.

METHODS

This was a retrospective, observational cohort study in an academic, tertiary care ED. We enrolled 411 adult patients with severe sepsis and lactate ≥4.0 mmol/L (n = 203) or septic shock (n = 208) who received protocolized resuscitation from 2005 to 2009. Emergency department variables, microbial cultures, and in-hospital outcomes were obtained from the medical record. Multivariable regression was used to identify factors independently associated with in-hospital mortality.

RESULTS

Mean age was 59.5 ± 16.3 years; 57% were male. Mean lactate was 4.8 mmol/L (3.5-6.7), 54% had positive cultures, and 27% received vasopressors in the ED. One hundred and five (26%) patients died in-hospital. Age, active cancer, do-not-resuscitate status on ED arrival, lack of fever, hypoglycemia, and intubation were independently associated with increased in-hospital mortality. Lactate clearance and diabetes were associated with a decreased risk of in-hospital death.

CONCLUSIONS

We identified a number of factors that were associated with in-hospital mortality among ED patients with severe sepsis or septic shock despite treatment with early protocolized resuscitation. These findings provide insights into aspects of early sepsis care that can be targets for future intervention.

Do-not-resuscitate orders among advanced-stage Chinese lung cancer patients who died in hospital

PURPOSE

Do-not-resuscitate (DNR) orders are an important part of end-of-life care (EOL) for patients with incurable advanced lung cancer. The aim of this study was to investigate the clinical factors related to the acceptance of DNR orders by Chinese patients.

METHODS

This study was a retrospective analysis involving patients with advanced-stage (IIIB or IV) lung cancer who died in hospital at our center from August 2004 through August 2014. The patients' clinical characteristics and DNR forms were reviewed.

RESULTS

Of the 348 patients enrolled, 260 (74.7 %) provided DNR orders signed only by surrogates. The signing rate of DNR orders increased annually. The median interval from signing a DNR order to death was 1 day (range, 0-72 days). Patients with poor performance status (PS) (≥2) 1 week prior to death (OR, 3.395; 95 % CI, 1.536-7.502, P = 0.003) and relatively longer overall survival (OS) (>3 months) (OR, 2.464; 95 % CI, 1.566-4.472, P < 0.001) were more likely to sign DNR orders. CPR was performed on 10.3 % (27/260) of patients with DNR orders, and was withheld in 22.7 % (20/88) of patients without DNR orders.

CONCLUSIONS

The DNR order-signing rate has been increasing annually among terminal patients with lung cancer in China. DNR orders, all of which were signed by surrogates, were more likely to be accepted by patients with slowly deteriorating disease and longer OS. More effort should be taken to help patients and medical professionals establish a sensible understanding of EOL care, including DNR orders, at earlier points during the disease course.

TRIAD VI: how well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms?

BACKGROUND

Physician Orders for Life-Sustaining Treatment (POLST) documents are active medical orders to be followed with intention to bridge treatment across health care systems. We hypothesized that these forms can be confusing and jeopardize patient safety.

OBJECTIVES

The aim of this study was to determine whether POLST documents are confusing in the emergency department setting and how confusion impacts the provision or withholding of lifesaving interventions.

METHODS

Members of the Pennsylvania chapter of the American College of Emergency Physicians were surveyed between September and October 2013. Respondents were to determine code status and treatment decisions in scenarios of critically ill patients with POLST documents who emergently arrest. Combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and levels of treatment (full, limited, comfort measures) were represented. Responses were summarized as percentages and analyzed by subgroup using the Fisher exact test. P = 0.05 was considered significant. We defined confusion in response as absence of consensus (supermajority of 95%).

RESULTS

Our response rate was 26% (223/855). For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Physician age and experience significantly affected response rates; prior POLST education had no impact. In most scenarios depicted, responses reflected confusion over its interpretation.

CONCLUSIONS

Significant confusion exists among members of the Pennsylvania chapter of the American College of Emergency Physicians regarding the use of POLST in critically ill patients. This confusion poses risk to patient safety. Additional training and/or safeguards are needed to allow patient choice as well as protect their safety.

The Goals of Patient Care project: implementing a proactive approach to patient-centred decision-making

BACKGROUND

Patients in the later stages of their lives risk being harmed by futile or unwanted interventions if realistic care goals and patient values are not recognised. Doctors have difficulty discussing and informing patients' healthcare goals.

AIMS

To review implementation of a Goals of Patient Care (GOPC) summary in medical inpatients and its applicability in emergency medical response (EMR) situations.

METHODS

Single-centre cross-sectional study of adult medical inpatients and adult inpatients requiring EMR at a Victorian general hospital.

MEASURES

presence and content of GOPC summary, secondary review of decision-making and discussion documentation, patient characteristics; EMR precipitants and outcomes.

RESULTS

GOPC were documented for 82 of 101 patients. One had an existing advance directive, and six had records of a patient-appointed substitute decision-maker. For patients with GOPC, 80 had life-prolonging treatment aims, with a varying degree of treatment limitation in 48. Discussion with patient or substitute decision-maker was evident in 43 cases. GOPC were documented prior to nine of 23 EMR. The EMR triggered a GOPC modification in three instances.

CONCLUSIONS

Introduction of a routine GOPC summary encourages consideration of goals of care for most medical inpatients. Few have pre-existing records of their wishes, and there are opportunities for improvement in this regard. Doctors may still have difficulty determining goals of care, and discussion of GOPC with patients and families may not be clearly documented. Most patients requiring EMR do not have prior GOPC review, and the role of the summary in these situations remains unclear.

Patients' characteristics associated with the decision of "do not attempt cardiopulmonary resuscitation" order in a Swiss hospital

BACKGROUND

According to Swiss legislation, do not attempt cardiopulmonary resuscitation (DNACPR) order can be made at any time by patients only, unless the resuscitation is considered as futile, based on the doctors' evaluation. Little is known about how this decision is made, and which are the factors influencing this decision.

METHODS

Observational, cross-sectional study was conducted between March and May 2013 on 194 patients hospitalized in the general internal medicine ward of a Swiss hospital. The associations between patients' DNACPR orders and gender, age, marital status, nationality, religion, number and type of comorbidities were assessed.

RESULTS

102 patients (53%) had a DNACPR order: 27% issued by the patient him/herself, 12% by his/her relatives and 61% by the medical team. Patients with a DNACPR order were significantly older: 80.7 ± 10.8 vs. 67.5 ± 15.1 years in the "with" and "without" DNACPR order group, respectively, p < 0.001. Oncologic disease was associated with a DNACPR order issued by the medical team (37.5% vs. 16.9% in the "with" and "without" DNACPR order group, respectively, p < 0.05). Being protestant was associated with a DNACPR order issued by the patient (57.9% vs. 25.9% in the "with" and "without" DNACPR order group, respectively p < 0.01).

CONCLUSIONS

Over half of the patients admitted to a general internal medicine ward had a DNACPR order issued within the first 72 h of hospitalization. Older age and oncologic disease were associated with a DNACPR decision by the medical team, while protestant religion was associated with a DNACPR decision by the patient.

Changing Trends in, and Characteristics Associated with, Not Undergoing Cardiac Catheterization in Elderly Adults Hospitalized with ST-Segment Elevation Acute Myocardial Infarction

OBJECTIVES

To describe decade- long trends (1999-2009) in the rates of not undergoing cardiac catheterization and percutaneous coronary intervention (PCI) in individuals aged 65 and older presenting with an ST-segment elevation acute myocardial infarction (STEMI) and factors associated with not undergoing these procedures.

DESIGN

Observational population-based study.

SETTING

Worcester, Massachusetts, metropolitan area.

PARTICIPANTS

Individuals aged 65 and older hospitalized for an STEMI in six biennial periods between 1999 and 2009 at 11 central Massachusetts medical centers (N=960).

MEASUREMENTS

Analyses were conducted to examine the characteristics of people who did not undergo cardiac catheterization overall and stratified into two age strata (65-74, ≥75).

RESULTS

Between 1999 and 2009, dramatic declines (from 59.4% to 7.5%) were observed in the proportion of older adults who did not undergo cardiac catheterization at all greater Worcester hospitals. These declines were observed in individuals aged 65 to 74 (58.4-6.7%) and in those aged 75 and older (69.4-13.5%). The proportion of individuals not undergoing PCI after undergoing cardiac catheterization decreased from 36.6% in 1999 to 6.5% in 2009. Women, individuals with a prior MI, those with do-not-resuscitate orders, and those with various comorbidities were less likely to have undergone these procedures than comparison groups.

CONCLUSION

Older adults who develop an STEMI are increasingly likely to undergo cardiac catheterization and PCI, but several high-risk groups remain less likely to undergo these procedures.

Influence of Patient Goals of Care on Performance Measures in Patients Hospitalized for Heart Failure: An Analysis of the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) Registry

BACKGROUND

Pay for performance programs compare metrics that are risk-adjusted, but goals of care are not considered in current models. We conducted this study to explore the associations between do not resuscitate (DNR) designations, quality of care, and outcomes.

METHODS AND RESULTS

Retrospective cohort study with chart review for inpatient quality metrics, 30 day mortality, and readmissions or death within 30 days of discharge in 96 Ontario hospitals participating in the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) study in 2004/05. Of 8339 patients (mean age 77 years) with new heart failure, 1220 (15%) had DNR documented at admission (admission DNR, varying from 0% to 36% between hospitals) and 892 (11%) were switched from full resuscitation to DNR during their index hospitalization (later DNR). Death at 30 days was more common in patients with admission DNR (27%) or later DNR (35%) than full resuscitation (3%)-admission DNR was a stronger predictor (adjusted OR 8.6, 95% confidence interval 6.8-10.7) than any of the variables currently included in heart failure 30 day mortality risk models. Hospital-level rankings differed considerably if DNR patients were excluded: 22 of the 39 EFFECT hospitals in the top and bottom quintiles for 30 day mortality rates (the usual thresholds for rewards/penalties in current performance-based reimbursement schemes) would not have been in those same quintiles if admission DNR patients were excluded.

CONCLUSIONS

Alternate goals of care are frequent and important confounders in heart failure comparative studies. Philosophy of care discussions should be considered for inclusion as a potential quality of care indicator.

The epidemiology of do-not-resuscitate orders in patients with trauma: a community level one trauma center observational experience

Background

Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients.

Methods

We included all adults with trauma to a community Level I Trauma Center over 6 years (2008–2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications).

Results

Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3–8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay.

Conclusions

Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0094-2) contains supplementary material, which is available to authorized users.

Development of the Universal Form Of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a cross-disciplinary approach

RATIONALE AIMS AND OBJECTIVES

Problems exist with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: they are often misinterpreted by clinicians to mean that other treatments should be withheld; resuscitation decision discussions are difficult; patients remain inappropriately for resuscitation. We developed an alternative approach.

METHODS

An adapted Delphi method was used. Senior clinicians were interviewed about the strengths and weakness of current practice. Teams who had initiated alternative approaches internationally were contacted. Focus groups were conducted with doctors, nurses and patients to further understand problems with DNACPR orders and establish essential aspects of a new approach. A behavioral economist and management consultant contributed advice. The resulting form was recirculated and further refined. It was: snowballed out to others with specialist expertise (palliative care physicians, intensivists, etc) for further feedback; assessed in simulated clinical encounters before being piloted; further adjusted once in clinical practice. In parallel, a patient information leaflet was developed along with education materials.

RESULTS

Consensus was achieved that the new approach should: be universal; have discussions and clinical conditions documented first; clarify goals of overall treatment (active treatment or optimal supportive care); contextualize the resuscitation decision among other treatment decisions; have a free text box for 'opting out' of invasive treatments, rather than tick boxes; be green; be limited to one page.

CONCLUSIONS

The Universal Form of Treatment Options was developed iteratively with patients, doctors and nurses as an alternative approach to resuscitation decisions. This paper illustrates a cross-disciplinary approach to developing practical alternatives in health care.

Jordanian critical care nurses' attitudes toward and experiences of do not resuscitate orders

BACKGROUND

Do not resuscitate (DNR) decisions are an issue of considerable sensitivity for patients and their relatives, as well as health professionals.

PURPOSE

The aim of this study was to explore Jordanian critical care nurses' attitudes towards and experiences of DNR decisions in clinical practice.

METHODS

A cross-sectional survey design was used. The sample consisted of 111 nurses working in intensive care units in three government hospitals in Jordan.

RESULTS

Fifty nine per cent of the participants were female. Most were under the age of 35 (69%) and 75% had a bachelor's degree. Most (67%) thought that the patient's family should be involved in DNR decision making. The majority (81%) reported that they preferred a coding system documenting DNR decisions in either the physician or nursing notes. Fifty eight per cent agreed that a standard DNR form should be kept with the patient's medical notes. Only 21% reported actual participation in DNR decisions.

CONCLUSION

This study demonstrates that Jordanian critical care nurses are willing to participate in DNR discussions and decision-making processes. Each hospital in the country should have a written DNR policy to guide and discipline health-care providers' practice.

Differentiating DNI from DNR: combating code status conflation

Goals of care discussions, including those focused on code status, are meant to foster autonomous decision making. Unfortunately, these discussions often conflate decisions regarding the use of cardiopulmonary resuscitation for cardiac arrest and mechanical ventilation for prearrest respiratory failure. They also exclude discussions of outcomes, particularly those associated with prearrest respiratory failure. In doing so, they may fail in their intention of extending patient autonomy. Journal of Hospital Medicine 2014;9:669-670. © 2014 Society of Hospital Medicine.

Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock*

OBJECTIVES

To assess the importance of including do-not-resuscitate status in critical care observational comparative effectiveness research.

DESIGN

Retrospective analysis.

SETTING

All California hospitals participating in the 2007 California State Inpatient Database, which provides do-not-resuscitate status within the first 24 hours of admission.

PATIENTS

Septic shock present at admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We investigated the association of early do-not-resuscitate status with in-hospital mortality among patients with septic shock. We also examined the strength of confounding of do-not-resuscitate status on the association between activated protein C therapy and mortality, an association with conflicting results between observational and randomized studies. We identified 24,408 patients with septic shock; 19.6% had a do-not-resuscitate order. Compared with patients without a do-not-resuscitate order, those with a do-not-resuscitate order were significantly more likely to be older (75 ± 14 vs 67 ± 16 yr) and white (62% vs 53%), with more acute organ failures (1.44 ± 1.15 vs 1.38 ± 1.15), but fewer inpatient interventions (1.0 ± 1.0 vs 1.4 ± 1.1). Adding do-not-resuscitate status to a model with 47 covariates improved mortality discrimination (c-statistic, 0.73-0.76; p < 0.001). Addition of do-not-resuscitate status to a multivariable model assessing the association between activated protein C and mortality resulted in a 9% shift in the activated protein C effect estimate toward the null (odds ratio from 0.78 [95% CI, 0.62-0.99], p = 0.04, to 0.85 [0.67-1.08], p = 0.18).

CONCLUSIONS

Among patients with septic shock, do-not-resuscitate status acts as a strong confounder that may inform past discrepancies between observational and randomized studies of activated protein C. Inclusion of early do-not-resuscitate status into more administrative databases may improve observational comparative effectiveness methodology.

Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching

BACKGROUND

Do-Not-Resuscitate (DNR) patients tend to receive less medical care after the order is written. To provide a clearer approach, the Ohio Department of Health adopted the Do-Not-Resuscitate law in 1998, indicating two distinct protocols of DNR orders that allow DNR patients to choose the medical care: DNR Comfort Care (DNRCC), implying DNRCC patients receive only comfort care after the order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), implying that DNRCC-Arrest patients are eligible to receive aggressive interventions until cardiac or respiratory arrest. The aim of this study was to examine the medical care provided to patients with these two distinct protocols of DNR orders.

METHODS

Data were collected from August 2002 to December 2005 at a medical intensive care unit in a university-affiliated teaching hospital. In total, 188 DNRCC-Arrest patients, 88 DNRCC patients, and 2,051 non-DNR patients were included. Propensity score matching using multivariate logistic regression was used to balance the confounding variables between the 188 DNRCC-Arrest and 2,051 non-DNR patients, and between the 88 DNRCC and 2,051 non-DNR patients. The daily cost of intensive care unit (ICU) stay, the daily cost of hospital stay, the daily discretionary cost of ICU stay, six aggressive interventions, and three comfort care measures were used to indicate the medical care patients received. The association of each continuous variable and categorical variable with having a DNR order written was analyzed using Student's t-test and the χ2 test, respectively. The six aggressive interventions and three comfort care measures performed before and after the order was initiated were compared using McNemar's test.

RESULTS

DNRCC patients received significantly fewer aggressive interventions and more comfort care after the order was initiated. By contrast, for DNRCC-Arrest patients, the six aggressive interventions provided were not significantly decreased, but the three comfort care measures were significantly increased after the order was initiated. In addition, the three medical costs were not significantly different between DNRCC and non-DNR patients, or between DNRCC-Arrest and non-DNR patients.

CONCLUSIONS

When medical care provided to DNR patients is clearly indicated, healthcare professionals will provide the medical care determined by patient/surrogate decision-makers and healthcare professionals, rather than blindly decreasing medical care.

Epidemiology and outcomes in patients with severe sepsis admitted to the hospital wards

PURPOSE

The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsis admitted from the emergency department to a non-intensive care unit (ICU) setting and identify risk factors associated with adverse outcomes.

MATERIAL AND METHODS

This was a single-center retrospective cohort study conducted at a tertiary, academic hospital in the United States between 2005 and 2009. The primary outcome was a composite outcome of ICU transfer within 48 hours of admission and/or 28-day mortality.

RESULTS

Of 1853 patients admitted with severe sepsis, 841 (45%) were admitted to a non-ICU setting, the rate increased over time (P < .001), and 12.5% of these patients were transferred to the ICU within 48 hours and/or died within 28 days. In multivariable models, age (P < .001), an oncology diagnosis (P < .001), and illness severity as measured by Acute Physiologic and Chronic Health Evaluation II (P = .04) and high (≥4 mmol/L) initial serum lactate levels (P = .005) were associated with the primary outcome.

CONCLUSIONS

Patients presenting to the emergency department with severe sepsis were frequently admitted to a non-ICU setting, and the rate increased over time. Of 8 patients admitted to the hospital ward, one was transferred to the ICU within 48 hours and/or died within 28 days of admission. Factors present at admission were identified that were associated with adverse outcomes.