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

Clinical Outcome after Intra-Arterial Stroke Therapy in the Very Elderly: Why is it so Heterogeneous?

Very elderly patients (i.e., ≥80 years) are disproportionally affected by acute ischemic stroke. They account for a third of hospital stroke admissions, but two-thirds of overall stroke-related morbidity and mortality. There is some evidence of clinical benefit in treating selected very elderly patients with intravenous thrombolysis (IVT). For very elderly patients ineligible or non-responsive to IVT, intra-arterial therapy (IAT) may have promise in improving clinical outcome. However, its unequivocal efficacy in the general population remains to be proven in randomized trials. Small cohort studies reveal that the rate of good clinical outcome for very elderly patients after IAT is highly variable, ranging from 0 to 28%. In addition, they experience higher rates of futile reperfusion than younger patients. Thus, it is imperative to understand the factors that impact on clinical outcome in very elderly patients after IAT. The aim of this review is to examine the factors that may be responsible for the heterogeneous clinical response of the very elderly to IAT. This will allow the reader to integrate the current available evidence to individualize intra-arterial stroke therapy in very elderly patients. Placing emphasis on pre-stroke independent living, smaller infarct core size, short procedure times, and avoiding general anesthesia where feasible, will help improve rates of good clinical outcome.

Elderly patients and intra-arterial stroke therapy

Ischemic stroke disproportionately affects the elderly, particularly those over the age of 80 years. Rates of stroke are expected to increase over the next several decades due to increasing numbers of elderly individuals, making understanding stroke treatment in this population an imperative. The only proven acute stroke therapy is early reperfusion, accomplished through intravenous or intra-arterial means. Intra-arterial stroke therapy (IAT) offers higher recanalization rates than intravenous tissue plasminogen activator, but has yet to show clear superiority over intravenous tissue plasminogen activator alone. Existing data suggest that elderly stroke patients suffer worse outcomes following IAT, despite similar rates of recanalization and symptomatic intracranial hemorrhage. This article reviews the application of IAT in the elderly population and summarizes the available studies that investigate the response of elderly patients to IAT.

Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage

BACKGROUND AND PURPOSE

Do-not-resuscitate orders may be associated with poor outcome in patients with intracerebral hemorrhage because of less active management.

AIMS

We sought to characterize the practice of issuing do-not-resuscitate orders in intracerebral hemorrhage. We also aimed to identify possible differences in care according to do-not-resuscitate status.

METHODS

We conducted a retrospective study of all consecutive intracerebral hemorrhage patients admitted to the Meilahti Hospital of the Helsinki University Central Hospital between January 2005 and March 2010. Data obtained from medical records allowed comparison of characteristics of patients and care of do-not-resuscitate and non-do-not-resuscitate patients as well as patients with early (within 24 h) and late (>24 h) do-not-resuscitate decisions. Logistic regression was used to identify factors independently associated with do-not-resuscitate decisions.

RESULTS

Of our 1013 patients, a do-not-resuscitate order was issued in 368 (35%), of which 262 (73%) occurred within 24 h from admission. Advanced age (odds ratio 1·06 per year; 95% confidence interval 1·04-1·08), more severe stroke (1·09 per National Institutes of Health Stroke Scale point; 1·06-1·13), and deterioration soon after admission (5·12, 3·33-7·87) had the strongest associations with do-not-resuscitate decisions. Patients with do-not-resuscitate orders received recommended care including stroke unit care (43% vs. 64%; P < 0·001) and prophylaxis for deep venous thrombosis (45% vs. 54%; P = 0·027) less often than non-do-not-resuscitate patients. This was especially the case when the do-not-resuscitate order was issued early.

CONCLUSIONS

In addition to confirming the role of known intracerebral hemorrhage prognostic factors in do-not-resuscitate decision-making, our results demonstrate that do-not-resuscitate orders led to less active care of intracerebral hemorrhage patients.

The Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a mixed methods evaluation of the effects on clinical practice and patient care

AIMS

To determine whether the introduction of the Universal Form of Treatment Options (the UFTO), as an alternative approach to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, reduces harms in patients in whom a decision not to attempt cardiopulmonary resuscitation (CPR) was made, and to understand the mechanism for any observed change.

METHODS

A mixed-methods before-and-after study with contemporaneous case controls was conducted in an acute hospital. We examined DNACPR (103 patients with DNACPR orders in 530 admissions) and UFTO (118 decisions not to attempt resuscitation in 560 admissions) practice. The Global Trigger Tool was used to quantify harms. Qualitative interviews and observations were used to understand mechanisms and effects.

RESULTS

RATE OF HARMS IN PATIENTS FOR WHOM THERE WAS A DOCUMENTED DECISION NOT TO ATTEMPT CPR WAS REDUCED: Rate difference per 1000 patient-days was 12.9 (95% CI: 2.6-23.2, p-value=0.01). There was a difference in the proportion of harms contributing to patient death in the two periods (23/71 in the DNACPR period to 4/44 in the UFTO period (95% CI 7.8-36.1, p-value=0.006). Significant differences were maintained after adjustment for known confounders. No significant change was seen on contemporaneous case control wards. Interviews with clinicians and observation of ward practice revealed the UFTO helped provide clarity of goals of care and reduced negative associations with resuscitation decisions.

CONCLUSIONS

Introducing the UFTO was associated with a significant reduction in harmful events in patients in whom a decision not to attempt CPR had been made. Coupled with supportive qualitative evidence, this indicates the UFTO improved care for this vulnerable group.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN85474986 UK Comprehensive Research Network Portfolio 7932.

Life-sustaining treatment preferences: matches and mismatches between patients' preferences and clinicians' perceptions

CONTEXT

Better clinician understanding of patients' end-of-life treatment preferences has the potential for reducing unwanted treatment, decreasing health care costs, and improving end-of-life care.

OBJECTIVES

To investigate patient preferences for life-sustaining therapies, clinicians' accuracy in understanding those preferences, and predictors of patient preference and clinician error.

METHODS

This was an observational study of 196 male veterans with chronic obstructive pulmonary disease who participated in a randomized trial. Measures included patients' preferences for mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) if needed in their current state of health, and outpatient clinicians' beliefs about those preferences.

RESULTS

Analyses were based on 54% of participants in the trial who had complete patient/clinician data on treatment preferences. Patients were more receptive to CPR than MV (76% vs. 61%; P<0.001). Preferences for both treatments were significantly associated with the importance patients assigned to avoiding life-sustaining therapies during the final week of life (MV: b=-0.11, P<0.001; CPR: b=-0.09, P=0.001). When responses were dichotomized (would/would not want treatment), clinicians' perceptions matched patient preferences in 75% of CPR cases and 61% of MV cases. Clinician errors increased as patients preferred less aggressive treatment (MV: b=-0.28, P<0.001; CPR: b=-0.32, P<0.001).

CONCLUSION

Clinicians erred more often about patients' wishes when patients did not want treatment than when they wanted it. Treatment decisions based on clinicians' perceptions could result in costly and unwanted treatments. End-of-life care could benefit from increased clinician-patient discussion about end-of-life care, particularly if discussions included patient education about risks of treatment and allowed clinicians to form and maintain accurate impressions of patients' preferences.

Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study

BACKGROUND

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders have been shown to be independently associated with patients receiving fewer treatments, reduced admission to intensive care and worse outcomes even after accounting for known confounders. The mechanisms by which they influence practice have not previously been studied.

OBJECTIVES

To present a rich qualitative description of the use of the DNACPR form in a hospital ward setting and explore what influence it has on the everyday care of patients.

DESIGN

Multi-source qualitative study, primarily using direct observation and semi-structured interviews based on two acute wards in a typical middle-sized National Health Service hospital in UK.

RESULTS

The study identified a range of ways in which DNACPR orders influence ward practice, beyond dictating whether or not cardiopulmonary resuscitation should be attempted. Five key themes encapsulate the range of potential impacts emerging from the data: the specific design and primacy of the form, matters relating to clinical decision making, staff reflections on how the form can affect care, staff concern over 'inappropriate' resuscitation, and discussions with patients/relatives about DNACPR decisions. Overall, it was found that while the DNACPR form is recognized as serving a useful purpose, its influence negatively permeated many aspects of clinical practice.

CONCLUSION

DNACPR orders can act as unofficial 'stop' signs and can often signify the inappropriate end to clinical decision making and proactive care. Many clinicians were uncomfortable discussing DNACPR orders with patients and families. These findings help understand why patients with DNACPR orders have worse outcomes, as such they may inform improvements in resuscitation policies.

An overview of end-of-life issues in the intensive care unit

The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.

The ethics of health care reform: impact on emergency medicine

The recent enactment of the Patient Protection and Affordable Care Act (ACA) of 2010, and the ongoing debate over reform of the U.S. health care system, raise numerous important ethical issues. This article reviews basic provisions of the ACA; examines underlying moral and policy issues in the U.S. health care reform debate; and addresses health care reform's likely effects on access to care, emergency department (ED) crowding, and end-of-life care. The article concludes with several suggested actions that emergency physicians (EPs) should take to contribute to the success of health care reform in America.

Quality of resuscitation orders in general medical patients

BACKGROUND

Documentation of resuscitation status in hospitalized patients has relevance in the management of cardiopulmonary arrest. Its association with mortality, Length Of hospital Stay (LOS) and the patients' primary diagnosis has not been established in general medical inpatients in hospitals in Australia and New Zealand.

AIM

To investigate the association of resuscitation orders with in-hospital mortality and LOS in a range of diagnoses, adjusting for severity of illness and other covariates.

DESIGN

Retrospective study.

METHODS

The admission notes of 1681 medical admissions to four tertiary care teaching hospitals across Australia and New Zealand were reviewed retrospectively for frequency and nature of resuscitation documentation and its association with mortality, LOS and primary diagnosis.

RESULTS

Resuscitation orders were documented in 741 patients (44.7%). For the 232 patients with a Not For Resuscitation (NFR) order, the in-hospital mortality rate was higher than in control patients (14% vs. 1.2%, P<0.005). The mortality rate remained significantly higher in the NFR group after propensity matching of the controls for age and co-morbidity (14% vs. 5%, P<0.005). The death-adjusted LOS for the NFR group was also significantly higher compared to the control patients (9.7 days vs. 4.7 days, P<0.005) and this difference remained after propensity matching (9.7 days vs. 7.7 days, P<0.05). Those patients with a primary diagnosis of respiratory tract infection or cardiac failure were more likely to be documented NFR compared to those with cellulitis or urinary tract infection.

CONCLUSIONS

The documentation of NFR in a patient's admission notes is associated with increased in-hospital mortality and LOS. This is only partly explicable in terms of these patients' greater age and co-morbidity.

Hospital do-not-resuscitate orders: why they have failed and how to fix them

Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.

Partial do-not-resuscitate orders: A hazard to patient safety and clinical outcomes?

BACKGROUND

Patients and families commonly discuss end-of-life decisions with clinicians to create a treatment plan based on patient wishes. In some instances, respect for patient autonomy in making choices may create the potential for patient harm. Medical treatments are often performed in groupings in order to work effectively. When such combinations are separated as a result of patient or surrogate choices, critical elements of life- saving care may be omitted, and the patient may receive nonbeneficial or harmful treatment. A partial do-not-resuscitate order may serve as an example.

LITERATURE REVIEW AND DISCUSSION

The limited literature available regarding partial do-not-resuscitate order(s) suggests the practice is clinically and ethically problematic. Not much is known about the prevalence of these orders, but some clinicians believe they are a growing phenomenon. Medical and bioethics organizations have produced guidelines and recommendations on the use of full do-not-resuscitate order(s) with little mention of partial do-not-resuscitate order(s). Partial do-not-resuscitate order(s) are designed based on the patient's anticipated need for resuscitation and are intended to manage dying in a tolerable manner based on what the decision maker believes is "best." Through an analysis of the medical literature, we propose that a partial do-not-resuscitate order contradicts this "best" management intention because it is impossible for the decision maker, or care providers, to anticipate all possible prearrest and arrest situations. We propose that a partial do-not-resuscitate order highlights larger problems: 1) a misunderstanding of the meaning and scope of a do-not-resuscitate order and 2) a need for discussions around goals of care.

CONCLUSION

Discouraging partial do-not-resuscitate(s) order may help promote more accurate and comprehensive advance care planning.

Do-not-attempt-resuscitation orders and prognostic models for intraparenchymal hemorrhage

OBJECTIVES

Statistical models predicting outcome after intraparenchymal hemorrhage include patients irrespective of do-not-attempt-resuscitation orders. We built a model to explore how the inclusion of patients with do-not-attempt-resuscitation orders affects intraparenchymal hemorrhage prognostic models.

DESIGN

Retrospective, observational cohort study from May 2001 until September 2003.

SETTING

University-affiliated tertiary referral hospital in Seattle, WA.

PATIENTS

Four hundred twenty-four consecutive patients with spontaneous intraparenchymal hemorrhage.

MEASUREMENTS AND MAIN RESULTS

We retrospectively abstracted information from medical records of intraparenchymal hemorrhage patients admitted to a single hospital. Using multivariate logistic regression of presenting clinical characteristics, but not do-not-attempt-resuscitation status, we generated a prognostic score for favorable outcome (defined as moderate disability or better at discharge). We compared observed probability of favorable outcome with that predicted, stratified by do-not-attempt-resuscitation status. We then generated a modified prognostic score using only non-do-not-attempt-resuscitation patients. Records of 424 patients were reviewed: 44% had favorable outcome, 43% had a do-not-attempt-resuscitation order, and 38% died in hospital. The observed and predicted probability of favorable outcome agreed well with all patients taken together. The observed probability of favorable outcome was significantly higher than predicted in non-do-not-attempt-resuscitation patients and significantly lower in do-not-attempt-resuscitation patients. Results were similar when applying a previously published and validated prognostic score. Our modified prognostic score was no longer pessimistic in non-do-not-attempt-resuscitation patients but remained overly optimistic in do-not-attempt-resuscitation patients.

CONCLUSIONS

Although our prognostic model was well-calibrated when assessing all intraparenchymal hemorrhage patients, predictions were significantly pessimistic in patients without and optimistic in those with do-not-attempt-resuscitation orders. Such pessimism may drive decisions not to attempt resuscitation in patients in whom a favorable outcome may have been possible, thereby creating a self-fulfilling prophecy. To be most useful in clinical decision making, intraparenchymal hemorrhage prognostic models should be calibrated to large intraparenchymal hemorrhage cohorts in whom do-not-attempt-resuscitation orders were not used.

Changes in medical care at a pediatric oncology referral center after placement of a do-not-resuscitate order

OBJECTIVE

Parents may fear that a do-not-resuscitate (DNR) order will result in reduction of the level, quality, and priority of their child's medical care. We therefore assessed medical care that was continued, added, and discontinued after a DNR order was placed in the medical record.

PATIENTS/METHODS

Retrospective review of the charts of 200 pediatric oncology patients at St. Jude Children's Research Hospital who died between July 1, 2001 and February 28, 2005, were younger than 22 years old at death, and had a documented DNR order. Medical interventions that were added (between the DNR order and death), continued (not discontinued between 24 hours before and 72 hours after DNR), and discontinued (within 72 hours after DNR) were identified and compared by using binomial proportions.

RESULTS

With the exception of chemotherapy, the studied medical interventions that patients were receiving at the time of the DNR order were continued in 66.7% to 99.3% of cases. Chemotherapy was continued in 33.3%. The most frequently added interventions were oxygen, steroids, and pain medicine. The most frequently discontinued interventions were laboratory draws, chemotherapy, antibiotics, and parenteral nutrition.

CONCLUSIONS

In this cohort of pediatric oncology patients, the medical interventions being received were continued with a high frequency after placement of a DNR order. Chemotherapy was continued only in a minority of patients, possibly signifying a shift in goals. These findings may help to reassure families that a DNR order need not result in a change in any of their child's medical therapies which appropriately advance the defined goals of care.

Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects

Since their introduction as 'no code' in the 1980s and their later formalization to 'do not resuscitate' orders, such directions to withhold potentially life-extending treatments have been accompanied by multiple ethical issues. The arguments for when and why to instigate such orders are explored, including a consideration of the concept of futility, allocation of healthcare resources, and reaching a balance between quality of life and quality of death. The merits and perils of discussing such decisions with patients and/or their relatives are reviewed and the unintended implications of 'do not attempt resuscitation' orders are examined. Finally, the paper explores some alternative methods to approaching the resuscitation decision, and calls for empirical evaluation of such methods that may reduce the ethical dilemmas physicians currently face.

Interpretation and intent: a study of the (mis)understanding of DNAR orders in a teaching hospital

Do not attempt resuscitation (DNAR) orders have been shown to be subject to misinterpretation in the 1980s and 1990s. We investigated whether this was still the case, and examined what perceptions doctors and nurses had of what care patients with DNAR orders receive.

METHODS

Using an anonymous written questionnaire, we directly approached 50 doctors and 40 nurses from a range of medical specialities and grades in our teaching hospital.

RESULTS

All 50 physicians and 35/40 nurses took part. Using McNemar's test, there were highly significant differences (p<0.0001) in what doctors believed 'should' take place and what they perceived 'in practice' occurred on patients with DNAR orders in all areas questioned (e.g., frequency of nursing observations and contacting medical staff in the event of a patient's deterioration). Using Fisher's exact test, there were significant differences between what nursing staff thought occurred and what doctors thought should occur, for example, frequency of nursing observations (p<0.001), contacting the medical team (p=0.01) and giving fluids (p<0.005).

CONCLUSIONS

Despite widespread use of DNAR orders, they are still misunderstood. This article highlights the frequency with which DNAR orders are interpreted to mean that other care should be withheld. In addition, it shows that although some doctors know that this should not be the case, they believe that DNAR orders affect the care that their patients receive. We propose that options for more detailed care plans should be embedded within the resuscitation decision and documentation to improve communication and understanding.

A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program

OBJECTIVES

To evaluate the relationship between two methods to communicate treatment preferences (Physician Orders for Life-Sustaining Treatment (POLST) program vs traditional practices) and documentation of life-sustaining treatment orders, symptom assessment and management, and use of life-sustaining treatments.

DESIGN

Retrospective observational cohort study conducted between June 2006 and April 2007.

SETTING

A stratified, random sample of 90 Medicaid-eligible nursing facilities in Oregon, Wisconsin, and West Virginia.

PARTICIPANTS

One thousand seven hundred eleven living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay.

MEASUREMENTS

Life-sustaining treatment orders; pain, shortness of breath, and related treatments over a 7-day period; and use of life-sustaining treatments over a 60-day period.

RESULTS

Residents with POLST forms were more likely to have orders about life-sustaining treatment preferences beyond cardiopulmonary resuscitation than residents without (98.0% vs 16.1%, P<.001). There were no differences between residents with and without POLST forms in symptom assessment or management. Residents with POLST forms indicating orders for comfort measures only were less likely to receive medical interventions (e.g., hospitalization) than residents with POLST full treatment orders (P=.004), residents with traditional do-not-resuscitate orders (P<.001), or residents with traditional full code orders (P<.001).

CONCLUSION

Residents with POLST forms were more likely to have treatment preferences documented as medical orders than those who did not, but there were no differences in symptom management or assessment. POLST orders restricting medical interventions were associated with less use of life-sustaining treatments. Findings suggest that the POLST program offers significant advantages over traditional methods to communicate preferences about life-sustaining treatments.

Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting

BACKGROUND

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program was designed to ensure the full range of patient treatment preferences are honored throughout the health care system. Data are lacking about the use of POLST in the hospice setting.

OBJECTIVE

To assess use of the POLST by hospice programs, attitudes of hospice personnel toward POLST, the effect of POLST on the use of life-sustaining treatments, and the types of treatments options selected by hospice patients.

DESIGN

A telephone survey was conducted of all hospice programs in three states (Oregon, Wisconsin, and West Virginia) to assess POLST use. Staff at hospices reporting POLST use (n = 71) were asked additional questions about their attitudes toward the POLST. Chart reviews were conducted at a subsample of POLST-using programs in Oregon (n = 8), West Virginia (n = 5), and Wisconsin (n = 2).

RESULTS

The POLST is used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff interviewed believe the POLST is useful at preventing unwanted resuscitation (97%) and at initiating conversations about treatment preferences (96%). Preferences for treatment limitations were respected in 98% of cases and no one received unwanted cardiopulmonary resuscitation (CPR), intubation, intensive care, or feeding tubes. A majority of hospice patients (78%) with do-not-resuscitate (DNR) orders wanted more than the lowest level of treatment in at least one other category such as antibiotics or hospitalization.

CONCLUSIONS

The POLST is viewed by hospice personnel as useful, helpful, and reliable. It is effective at ensuring preferences for limitations are honored. When given a choice, most hospice patients want the option for more aggressive treatments in selected situations.

End-of-life issues in the acute and critically ill patient

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.

Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure

BACKGROUND

Heart failure (HF) is one of the leading causes of morbidity and mortality among Americans. Despite increased interest in end-of-life care, the implications of do-not-resuscitate (DNR) orders in acutely ill patients with HF remain unclear. The goals of this observational study were to describe the use of DNR orders and their impact on treatment approaches in residents of a large New England metropolitan area hospitalized with acute heart failure.

METHODS

Use of HF performance measures, including assessment of left ventricular function, use of angiotensin receptor blocking agents, anticoagulation, smoking cessation counseling, and use of nonpharmacologic strategies, was examined through review of the medical records of 4,537 metropolitan Worcester (MA) residents admitted to 11 central Massachusetts hospitals with acute HF in 1995 and 2000 according to the presence of DNR orders.

RESULTS

Patients with DNR orders were less likely to have had their left ventricular function assessed (31% vs 43%) as well as receive renin-angiotensin system blockade (49% vs 57%), anticoagulation (65% vs 78%), or nonpharmacologic interventions (87% vs 92%) as compared to patients without DNR orders. Patients with DNR orders were significantly less likely to have received any quality assurance measure for acute HF (adjusted hazard ratio 0.63, 95% confidence interval 0.40-0.99) than patients without DNR orders.

CONCLUSIONS

The use of quality assurance measures in acute HF is markedly lower in patients with DNR orders. The implications of DNR orders need to be further clarified in the treatment of patients with acute HF.

The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit

PURPOSE

To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center.

METHODS

Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score.

RESULTS

The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality.

CONCLUSION

The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.

Do-not-resuscitate orders, unintended consequences, and the ripple effect

Do-not-resuscitate (DNR) orders are commonly implemented in the critical care setting as a prelude to end-of-life care. This is often based on presumed prognosis for favorable outcome and interpretation of patient, family, and even physician wishes. While DNR orders explicitly apply only to an individual patient, the hospital culture and milieu in which DNR orders are implemented could potentially have an overall impact on aggressiveness of care across patients. As illustrated by the example of intracerebral hemorrhage, this may unexpectedly influence outcome even in patients without DNR orders in place.

Effect of decisions to withhold life support on prolonged survival

BACKGROUND

The effect on long-term mortality of decisions made to withhold life-supporting therapies (LST) for critically ill patients is unclear. We hypothesized that mortality 60 days after ICU admission is not influenced by a decision to withhold use of LST in the context of otherwise providing all indicated care.

METHODS

We studied 2,211 consecutive, initial admissions to the adult, medical ICU of a university-affiliated teaching hospital. To achieve balanced groups for comparing outcomes, we created a multivariable regression model for the probability (propensity score [PS]) of having an order initiated in the ICU to withhold LST. Each of the 201 patients with such an order was matched to the patient without such an order having the closest PS; mortality rates were compared between the matched pairs. Cox survival analysis was performed to extend the main analysis.

RESULTS

The matched pairs were well balanced with respect to all of the potentially confounding variables. Sixty days after ICU admission, 50.5% of patients who had an order initiated in the ICU to withhold life support had died, compared to 25.8% of those lacking such orders (risk ratio, 2.0; 95% confidence interval, 1.5 to 2.6). Survival analysis indicated that the difference in mortality between the two groups continued to increase for approximately 1 year.

CONCLUSION

Contrary to our hypothesis, decisions made in the ICU to withhold LST were associated with increased mortality rate to at least 60 days after ICU admission.

REPRINT

Purpose— The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

Methods— A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time.

Results— Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults

PURPOSE

The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time.

RESULTS

Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.

Characteristics, management, and outcomes of 5,557 patients age > or =90 years with acute coronary syndromes: results from the CRUSADE Initiative

OBJECTIVES

The goal of this work was to explore the treatment and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) age > or =90 years.

BACKGROUND

The elderly are often excluded from clinical trials of NSTE-ACS and are underrepresented in clinical registries.

METHODS

We used data from the CRUSADE registry to study 5,557 patients with NSTE-ACS age > or =90 years and compared their baseline characteristics, treatment patterns, and in-hospital outcomes with a cohort age 75 to 89 years (n = 46,270).

RESULTS

Although both groups had much in common, compared with the younger elderly, the older elderly were less likely to be diabetic, smokers, or obese. Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 h and were less likely to undergo cardiac catheterization within 48 h. The older elderly were more likely to die (12.0% vs. 7.8%) and experienced more frequent adverse events (26.8% vs. 21.3%) during the hospitalization-differences that persisted after adjustment for baseline patient and hospital characteristics. Increasing adherence to guideline-recommended therapies was associated with both increased bleeding and a graded reduction in risk-adjusted in-hospital mortality across both age groups.

CONCLUSIONS

In this large population of nonagenarians and centenarians with NSTE-ACS, increasing adherence to guideline-recommended therapies was associated with decreased mortality. These findings reinforce the importance of optimizing care patterns for even the oldest patients with NSTE-ACS, while examining novel approaches to reduce the risk of bleeding in this rapidly expanding patient population.

Death, dying, and last wishes

Issues regarding patient care near the end of life can be challenging and rewarding for emergency physicians. Knowledge of the patient's wishes is essential, and may be accomplished by advance directives or communication with patients and surrogates. Resuscitative efforts are appropriate for many patients, but inappropriate for others. The goals of medicine remain the following: providing optimal health care, provision of the best possible symptom control, communication, empathy, and caring. As death approaches, provision of the best possible medical care, in accordance with the patient's wishes, can be rewarding for patients, families, and health care providers.

Nursing home patients in the intensive care unit: Risk factors for mortality

OBJECTIVE

To determine intensive care unit (ICU) admission characteristics predictive of mortality among older nursing home residents.

DESIGN

Retrospective cohort study.

SETTING

A 725-bed teaching nursing home and two teaching-hospital ICUs.

PATIENTS

One hundred twenty-three nursing home residents > or =75 yrs admitted to the ICU between July 1, 1999, and September 30, 2003.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Characteristics of nursing home residents admitted to the ICU were identified by medical record review at the nursing home and the hospital. Additionally, the minimum data set was used to calculate preadmission functional status using the Activities of Daily Living-Long Form (ADL-L) and cognitive status with the Cognitive Performance Scale (CPS). Our primary outcomes were hospital mortality and mortality within 90 days of ICU admission. The nursing home residents admitted to the ICU were old (87.7 +/- 5.4 yrs) with impaired cognition (CPS 2.8 +/- 1.7, range 0-6, where 6 = most impaired) and moderately dependent function (ADL-L 14.5 +/- 9.4, range 0-28, where 28 = total dependence). Of the 123 patients, 33 (27%) died in the hospital, whereas 90 (73%) survived to hospital discharge. Acute Physiology and Chronic Health Evaluation (APACHE) III score was independently associated with significantly increased odds of hospital mortality (adjusted odds ratio 1.04; 95% confidence interval 1.02, 1.07). Among the 90 patients who survived to return to the nursing home, 34 (37.8%) died within 90 days. Cox regression demonstrated that higher APACHE III score (adjusted risk ratio 1.02; 95% confidence interval 1.01, 1.04) and increasing functional dependency before ICU admission (adjusted risk ratio 1.6; 95% confidence interval 1.05, 2.57, per ADL-L quartile) were independently associated with increased mortality rate within 90 days.

CONCLUSIONS

Among vulnerable elderly nursing home residents, higher APACHE III score is independently associated with increased hospital mortality rate and mortality within 90 days. Among hospital survivors, impaired functional status is independently associated with increased mortality rate within 90 days.