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Putot S, Jouanny P, Barben J, Mazen E, Da Silva S, Dipanda M, Asgassou S, Nuss V, Laborde C, Mihai AM, Vovelle J, Manckoundia P, Putot A. Level of Medical Intervention in Geriatric Settings: Decision Factors and Correlation With Mortality. J Am Med Dir Assoc 2021; 22:2587-2592. [PMID: 33992608 DOI: 10.1016/j.jamda.2021.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Level of medical intervention (LMI) has to be adapted to each patient in geriatric care. LMI scales intend to help nonintensive care (NIC) decisions, giving priority to patient choice and collegial discussion. In the present study, we aimed to assess the parameters associated with the NIC decision and whether these parameters differ from those associated with in-hospital mortality. DESIGN Prospective observational study. SETTING AND PARTICIPANTS All consecutive patients from a French 62-bed acute geriatric unit over 1 year. METHODS Factors from the geriatric assessment associated with the decision of NIC were compared with those associated with in-hospital and 1-year mortality, in univariate and multivariate analyses. RESULTS In total, 1654 consecutive patients (median age 87 years) were included. Collegial reflection led to NIC decision for 532 patients (32%). In-hospital and 1-year mortality were 22% and 54% in the NIC group vs 2% and 27% in the rest of the cohort (P < .001 for both). In multivariable analysis, high Charlson Comorbidity Index [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.06-1.23, per point], severe neurocognitive disorders (OR 2.78, 95% CI 1.67-4.55), dependence (OR 1.92, 95% CI 1.45-2.59), and nursing home residence (OR 2.38, 95% CI 1.85-3.13) were highly associated with NIC decision but not with in-hospital mortality. Conversely, acute diseases had little impact on LMI despite their high short-term prognostic burden. CONCLUSIONS AND IMPLICATIONS Neurocognitive disorders and dependence were strongly associated with NIC decision, even though they were not significantly associated with in-hospital mortality. The decision-making process of LMI therefore seems to go beyond the notion of short-term survival.
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Affiliation(s)
- Sophie Putot
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Pierre Jouanny
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France; Institut National de la Santé et de la Recherche Médicale U1093 Cognition Action Plasticité, Université de Bourgogne Franche-Comté, Dijon, Bourgogne Franche-Comté, France
| | - Jeremy Barben
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Emmanuel Mazen
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Sofia Da Silva
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Mélanie Dipanda
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Sanaa Asgassou
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Valentine Nuss
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Caroline Laborde
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Anca M Mihai
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Jérémie Vovelle
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France
| | - Patrick Manckoundia
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France; Institut National de la Santé et de la Recherche Médicale U1093 Cognition Action Plasticité, Université de Bourgogne Franche-Comté, Dijon, Bourgogne Franche-Comté, France
| | - Alain Putot
- Service de médecine interne gériatrie, Pôle Personnes Agées, Centre Hospitalier Universitaire, Dijon, Bourgogne Franche-Comté, France.
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Sarkari NN, Perman SM, Ginde AA. Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis. J Crit Care 2016; 36:134-139. [PMID: 27546762 DOI: 10.1016/j.jcrc.2016.06.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/26/2016] [Accepted: 06/29/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Do-not-attempt-resuscitation (DNAR) orders are common in severe sepsis, but the impact on clinical care is not known. Our primary objective was to determine the impact of early DNAR orders on in-hospital mortality and performance of key interventional procedures among severe sepsis hospitalizations. Our secondary objective was to further investigate what patient characteristics within the sepsis DNAR population affected outcomes. METHODS Using the 2010-2011 California State Inpatient Dataset, we analyzed hospitalizations for adults admitted through the emergency department with severe sepsis. Our primary predictor was a DNAR order, and our outcomes were in-hospital mortality and performance of interventional procedures. RESULTS Visits with early DNAR orders accounted for 20.3% of severe sepsis hospitalizations. An early DNAR order was a strong, independent predictor of higher in-hospital mortality (odds ratio [OR], 4.03; 95% confidence interval, 3.88-4.19) and lower performance of critical procedures: central venous line (OR, 0.70), mechanical ventilation (OR, 0.80), hemodialysis (OR, 0.61), and major operative procedure (OR, 0.46). Among those with early DNAR orders, older age and rural location were the strongest predictors for a lack of interventional procedures. CONCLUSION Although DNAR orders are not synonymous with "do not treat," they may unintentionally limit aggressive treatment for severe sepsis patients, especially in older adults.
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Affiliation(s)
- Neza N Sarkari
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
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