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

Unintended Consequences of Code Status in the Intensive Care Unit: What Happens After a Do-Not-Resuscitate Order Is Placed? A Retrospective Cohort Study

Background: Some clinicians suspect that patients with do-not-resuscitate (DNR) orders receive less aggressive care. Extrapolation from code status to goals of care could cause significant harm. This study asked the question: Do DNR orders in the intensive care unit (ICU) lead to a decrease in invasive interventions? Methods: This was a retrospective cohort study of ICU patients from three teaching hospitals. All ICU patients were assessed for inclusion. Exclusion criteria were medical futility and death, comfort care, or ICU discharge <48 hours after DNR initiation. Five hundred thirty-six patients met inclusion criteria. One hundred forty-five were included in the final analysis. Primary outcomes were occurrence of invasive interventions after DNR initiation-surgical operation, central line, ventilation, dialysis, or other procedure. Secondary outcomes were antibiotic administration, blood transfusion, mortality, and discharge location. Results: Patients with DNR orders underwent fewer surgical operations (14.5% vs. 31.1%, p = 0.002), but more central lines (42.1% vs. 23.0%, p = 0.009), ventilator use (49.0% vs. 18.9%, p < 0.001), and dialysis (20.0% vs. 4.1%, p = 0.002), compared with patients without DNR orders. Transfusions and antibiotic use decreased similarly over admission for both groups (transfusions: β = 1.25; p = 0.59; and antibiotics: β = 1.44; p = 0.27). Mortality and hospice discharges were higher for DNR patients (p < 0.001.). Conclusions: DNR status did not decrease the number of nonoperative interventions patients received as compared with full code counterparts. Although differences in populations existed, patients with DNR orders were likely to receive a similar number of invasive interventions. This finding suggests that providers do not wholesale limit these options for patients with code status limitations.

Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department

BACKGROUND

Predicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired.

METHODS

We advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year.

RESULTS

A total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74-0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69-0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56-0.57) by using SQ (surprise question), 0.54 (0.54-0.54) by using qSOFA, and 0.59 (0.59-0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic.

CONCLUSIONS

The A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.

Characteristics and outcomes of patients with do-not-resuscitate and physician orders for life-sustaining treatment in a medical intensive care unit: a retrospective cohort study

BACKGROUND

In the intensive care unit (ICU), we may encounter patients who have completed a Do-Not-Resuscitate (DNR) or a Physician Orders to Stop Life-Sustaining Treatment (POLST) document. However, the characteristics of ICU patients who choose DNR/POLST are not well understood.

METHODS

We retrospectively analyzed the electronic medical records of 577 patients admitted to a medical ICU from October 2019 to November 2020, focusing on the characteristics of patients according to whether they completed DNR/POLST documents. Patients were categorized into DNR/POLST group and no DNR/POLST group according to whether they completed DNR/POLST documents, and logistic regression analysis was used to evaluate factors influencing DNR/POLST document completion.

RESULTS

A total of 577 patients were admitted to the ICU. Of these, 211 patients (36.6%) had DNR or POLST records. DNR and/or POLST were completed prior to ICU admission in 48 (22.7%) patients. The DNR/POLST group was older (72.9 ± 13.5 vs. 67.6 ± 13.8 years, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (26.1 ± 9.2 vs. 20.3 ± 7.7, p < 0.001) and clinical frailty scale (5.1 ± 1.4 vs. 4.4 ± 1.4, p < 0.001) than the other groups. Solid tumors, hematologic malignancies, and chronic lung disease were the most common comorbidities in the DNR/POLST groups. The DNR/POLST group had higher ICU and in-hospital mortality and more invasive treatments (arterial line, central line, renal replacement therapy, invasive mechanical ventilation) than the other groups. Body mass index, APAHCE II score, hematologic malignancy, DNR/POLST were factors associated with in-hospital mortality.

CONCLUSIONS

Among ICU patients, 36.6% had DNR or POLST orders and received more invasive treatments. This is contrary to the common belief that DNR/POLST patients would receive less invasive treatment and underscores the need to better understand and include end-of-life care as an important ongoing aspect of patient care, along with communication with patients and families.

Early and late withdrawal of life-sustaining treatment after out-of-hospital cardiac arrest in the United Kingdom: Institutional variation and association with hospital mortality

AIM

Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients' risk-adjusted hospital mortality.

METHODS

We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010 and 2017. We identified patient and ICU characteristics associated with early (within 72 h) and late (>72 h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients' hospital mortality.

RESULTS

We included 28,438 patients across 204 ICUs. 10,775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients' hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p < 0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p < 0.001).

CONCLUSIONS

Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.

Impact of Receiving Hospital on Out-of-Hospital Cardiac Arrest Outcome: Racial and Ethnic Disparities in Texas

Background Factors associated with out-of-hospital cardiac arrest (OHCA) outcome disparities remain poorly understood. We evaluated the role of receiving hospital on OHCA outcome disparities. Methods and Results We studied people with OHCA who survived to hospital admission from TX-CARES (Texas Cardiac Arrest Registry to Enhance Survival), 2014 to 2021. Using census data, we stratified OHCAs into majority (>50%) strata: non-Hispanic White race and ethnicity, non-Hispanic Black race and ethnicity, and Hispanic or Latino ethnicity. We stratified hospitals into performance quartiles based on the primary outcome, survival with good neurologic outcome. We evaluated the association between race and ethnicity and care at higher-performance hospitals. We compared 3 models evaluating the association between race and ethnicity and outcome: (1) ignoring hospital, (2) adjusting for hospital as a random intercept, and (3) adjusting for hospital performance quartile. We adjusted models for possible confounders. We included 10 434 OHCAs. Hospital performance quartile outcome rates ranged from 11.3% (fourth) to 37.1% (first). Compared with OHCAs in neighborhoods of majority White race, those in neighborhoods of majority Black race (odds ratio [OR], 0.1 [95% CI, 0.1-0.1]) and Hispanic or Latino ethnicity (OR, 0.2 [95% CI, 0.2-0.2]) were less likely to be cared for at higher-performing hospitals. Compared with White neighborhoods (30.1%) and ignoring hospital, outcomes were worse in Black neighborhoods (15.4%; adjusted OR [aOR], 0.5 [95% CI, 0.4-0.5]) and Hispanic or Latino neighborhoods (19.2%; aOR, 0.6 [95% CI, 0.5-0.7]). Adjusting for hospital as a random intercept, outcomes improved for Black neighborhoods (aOR, 0.9 [95% CI, 0.7-1.05]) and Hispanic or Latino neighborhoods (aOR, 0.9 [95% CI, 0.8-0.99]). Adjusting for hospital performance quartile, outcomes improved for Black neighborhoods (aOR, 0.8 [95% CI, 0.7-1.01]) and Hispanic or Latino neighborhoods (aOR, 0.9 [95% CI, 0.8-0.996]). Conclusions In Black and Hispanic or Latino communities, OHCAs were less likely to be cared for at higher-performing hospitals, and adjusting for receiving hospital improved OHCA outcome disparities.

Comment on: Prevalence and Related Factors of Do-Not-Resuscitate Orders Among In-Hospital Cardiac Arrest Patients

We read the article by Tangxing Jiang et al. entitled "Prevalence and related factors of do-not-resuscitate orders among in-hospital cardiac arrest patients" with delight.1 This manuscript was beneficial to read, and the author's insights are admirable. We concur with the summary that newly diagnosed coronary artery disease patients are less likely to have a DNR order established. To enhance the standard of palliative care, DNR orders should be developed. However, we are compelled to present additional points that will strengthen the credibility of this report and add to the existing body of knowledge.

Knowledge and Attitude of the General Population About Do Not Resuscitate (DNR) in the Western Region, Saudi Arabia

BACKGROUND

A do-not-resuscitate (DNR) order is a medical order issued by a doctor. It directs medical professionals to refrain from performing cardiopulmonary resuscitation (CPR) if a patient's breathing or heartbeat ceases. Patients can refuse CPR in an emergency if they have a DNR order. The DNR order includes precise directives about CPR. Instructions for extra therapies like nourishment, other drugs, or painkillers are not included.

AIM

The aim of the study is to learn more about the western region's general population's knowledge and attitudes toward DNR orders and identify any challenges that may arise when dealing with DNR patients.

METHODOLOGY

A cross-sectional study was conducted in 2023 in the western region of Saudi Arabia. An online, self-administered questionnaire was distributed randomly from April 8, 2023 to June 6, 2023. The estimated sample size was 384, and 604 were the collected responses.

RESULTS

A total of 383 (63.4%) participants were females, and 221 (36.6%) were males. Regarding the knowledge and attitude of the general population about DNR orders in the western region of Saudi Arabia, 276 (45.7%) study participants had satisfactory knowledge and awareness, while 328 (54.3%) had inadequate knowledge. A total of 343 (56.8%) participants thought that DNR is important; 255 (42.2%) felt that the DNR has reduced the pain of their relatives, and 181 (30%) believed that it has reduced the stress felt by the patient's families. Of participants aged 20-30 years, 58.4% had satisfactory knowledge about DNR orders compared with those aged 50 and above; 76.1% of healthcare workers had satisfactory knowledge versus 26.5% of unemployed participants (P=.001).

CONCLUSION

We recommend increasing awareness and knowledge about DNR by conducting educational events about the concept and how to deal with patients who choose to acquire a DNR order.

Treatment and outcome variation in out-of-hospital cardiac arrest among four urban hospitals in Detroit

AIMS

To determine whether out-of-hospital cardiac arrest (OHCA) post-resuscitation management and outcomes differ between four Detroit hospitals.

INTRODUCTION

Significant variation exists in treatment/outcomes from OHCA. Disparities between hospitals serving a similar population is not well known.

METHODS

Retrospective OHCA data was collected from the Detroit-Cardiac Arrest Registry (DCAR) between January 2014 to December 2019. Four hospitals were compared on two treatments (angiography, do not resuscitate (DNR)) and two outcomes (cerebral performance category (CPC) ≤ 2, in-hospital death). Models for death and CPC were tested with and without coronary angiography and DNR status.

RESULTS

999 patients at hospitals A - D differed (p < 0.05) before multivariable adjustment by age, race, witnessed arrest, dispatch-emergency department (ED) time, TTM, coronary angiography, DNR order, and in-hospital death. Rates of death and CPC ≤ 2 were worse in Hospital A (82.8%, 10%, respectively) compared to others (69.1%, 14.1%). After multivariable adjustment, Hospital A performed angiography less compared to B (OR = 0.17) and was more likely to initiate new DNR status than B (OR = 2.9), C (OR = 16.1), or D (OR = 3.6). CPC ≤ 2 were worse in Hospital A compared to B (OR = 0.27) and D (OR = 0.35). After sensitivity analysis, CPC ≤ 2 odds did not differ for A versus B (OR = 0.58, adjusted for angiography) or D (OR = 0.65, adjusted for DNR). Odds of death, despite angiography and DNR differences, were worse in Hospital A compared to B (OR = 1.87) and D (OR = 1.81).

CONCLUSION

Differing rates of DNR and coronary angiography was associated with observed disparities in favorable neurologic outcome, but not death, between four Detroit hospitals.

Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized with COVID-19

BACKGROUND

Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access.

OBJECTIVE

To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19.

DESIGN

Retrospective cohort analysis of manually abstracted electronic medical records.

PATIENTS

7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR).

KEY RESULTS

Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)).

CONCLUSIONS

Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.

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

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

The intersection of prognostication and code status in patients with severe brain injury

Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.

Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study

BACKGROUND

Rapid response systems (RRSs) improve patients' safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS.

METHODS

Patients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock.

RESULTS

After propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients' overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75).

CONCLUSIONS

The presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.

Hospital length of stay, do not resuscitate orders, and survival for post-cardiac arrest patients in Michigan: A study for the CARES Surveillance Group

OBJECTIVE

Current guidelines recommend deferring prognostic decisions for at least 72 h following admission after Out of Hospital cardiac arrest (OHCA). Most non-survivors experience withdrawal of life sustaining therapy (WLST), and early WLST may adversely impact survival. We sought to characterize the hospital length of stay (LOS) and timing of Do Not Resuscitate (DNR) orders (as surrogates for WLST), to assess their relationship to survival following cardiac arrest.

DESIGN

We performed a retrospective cohort study of probabilistically linked cardiac arrest registries (Cardiac Arrest Registry to Enhance Survival (CARES) and Michigan Inpatient Database (MIDB) from 2014 to 2017.

PATIENTS

Adult (≥18 years) patients admitted following OHCA were included. We considered LOS ≤ 3 days (short LOS) and written DNR order with LOS ≤ 3 days (Early DNR) as indicators of early WLST. Our primary outcome was survival to hospital discharge. We utilized multilevel logistic regression clustered by hospital to examine associations of these variables, patient characteristics and survival to hospital discharge.

MEASUREMENT AND MAIN RESULTS

We included 3644 patients from 38 hospitals with >30 patients. Patients mean age was 62.4 years and were predominately male (59.3%). LOS ≤ 3 days (OR_adj = 0.11) and early DNR (OR_adj = 0.02) were inversely associated with survival to discharge. There was a non-significant inverse association between hospital rates of LOS ≤ 3 days and survival (p = 0.11), and Early DNR and survival (p = 0.83). In the multilevel model, using median odd ratios to assess variation in LOS ≤ 3 days and survival, patient characteristics contributed more to variability in surviival than between-hospital variation. However, between-hospital variation contributed more to variability than patient characteristics in the provision of early DNR orders.

CONCLUSIONS

We observed that LOS ≤ 3 days for post-arrest patients was negatively-associated with survival, with both patient characteristics and between-hospital variation associated with outcomes. However, between-hospital variation appears to be more highly-associated with provision of early DNR orders than patient characteristics. Further work is needed to assess variation in early DNR orders and their impact on patient survival.

A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department

BACKGROUND

Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department.

AIM

We developed a screening model for predicting 1-year mortality.

DESIGN

A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation.

SETTING AND PARTICIPANTS

Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department.

RESULTS

We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model.

CONCLUSIONS

A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.

Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders

Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age >85 years (adjusted odd ratios (AOR) 1.700, 1.027–2.814), living in long-term care facilities (AOR 1.880, 1.066–3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039–4.358), “medical staff would not be surprised if the patient died within 12 months” (AOR 1.725, 1.193–2.496), and patients’ family requesting palliative care (AOR 2.420, 1.187–4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p < 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p < 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.

Original Research: Nurses' Perspectives on Caring for Patients with Do-Not-Resuscitate Orders

BACKGROUND

Confusion about what a do-not-resuscitate (DNR) order means, including its misinterpretation as "do not treat," has been extensively documented in the literature. Yet there is a paucity of research concerning nurses' perspectives on DNR orders.

PURPOSE AND DESIGN

This mixed-methods study was designed to explore nurses' perspectives on the meaning and interpretation of DNR orders in relation to caring for hospitalized adults with such orders.

METHODS

Direct care nurses on three units in a large urban hospital were asked to respond online to a case study by indicating how they would prioritize care based on the patient's DNR designation. These nurses were then invited to participate in open-ended interviews with a nurse researcher. Interviews were audiotaped, transcribed, and analyzed.

FINDINGS

A total of 35 nurses responded to the case study survey. The majority chose to prioritize palliative care, despite no indication that any plan of care was in place. Thirteen nurses also completed a one-on-one interview. Analysis of interview data revealed this overarching theme: varying interpretations of DNR orders among nurses were common, resulting in unintended consequences. Participants also reported perceived variances among health care team members, patients, and family members. Such misinterpretations resulted in shifts in care, varying responses to deteriorating status, tension, and differences in role expectations for health care team members.

CONCLUSIONS

Nurses have opportunities to address misconceptions about care for patients with DNR orders through practice, education, advocacy and policy, and research.

Gender-Based Differences in Outcomes Among Resuscitated Patients With Out-of-Hospital Cardiac Arrest

BACKGROUND

Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival.

METHODS

Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants.

RESULTS

Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P<0.001 for all). A significantly higher proportion of women received DNR orders (35.7% versus 32.1%, P=0.009) and had WLST (32.8% versus 29.8%, P=0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P<0.001; adjusted odds ratio, 0.78 [95% CI, 0.66-0.93]; P=0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P=0.005; adjusted odds ratio, 0.74 [95% CI, 0.60-0.91]) or did not have WLST (32.3% versus 50.7%, P=0.002; adjusted odds ratio, 0.73 [95% CI, 0.60-0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P=0.90) or had WLST (2.8% versus 2.4%, P=0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort.

CONCLUSIONS

Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.

Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland

BACKGROUND

Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland.

METHODS

This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded.

RESULTS

There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001).

CONCLUSIONS

In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.

Perceptions of ICU Care Following Do-Not-Resuscitate Orders: A Military Perspective

Although do-not-resuscitate orders only prohibit cardiopulmonary resuscitation in the case of cardiac arrest, the common initiation of this code status in the context of end-of-life care may lead providers to draw premature conclusions about other goals of care. The aim of this study is to identify concerns regarding care quality in the setting of do-not-resuscitate orders within the Department of Defense and compare differences in perceptions between members of the critical care team.

Design

A cross sectional observational study was conducted.

Setting

This study took place in the setting of critical care within the Department of Defense.

Subjects

All members of the Uniformed Services Section of the Society of Critical Care Medicine were invited to participate.

Interventions

A validated 31-question survey exploring the perceptions of care quality in the setting of do-not-resuscitate status was distributed.

Measurements and Main Results

Exploratory factor analysis was used to categorically group survey questions, and average factor scores were compared between respondent groups using t tests. Responses to individual questions were also analyzed between comparison groups using Fisher exact tests. Factor analysis revealed no significant differences between respondents of different training backgrounds; however, those with do-not-resuscitate training were more likely to agree that active treatment would be pursued (p = 0.024) and that trust and communication would be maintained (p = 0.005). Although 38% of all respondents worry that quality of care will decrease, 93% agree that life-prolonging treatments should be offered. About a third of providers wrongly believed that a do-not-resuscitate order must be reversed prior to an operation.

Conclusions

Although providers across training backgrounds held similar concerns about decreased care quality in the ICU, there is wide belief that the routine and noninvasive interventions are offered as indicated. Those with do-not-resuscitate training were more likely to believe that standards of care continued to be met after code status change.

Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage

BACKGROUND

Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists.

METHODS

We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24 h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model.

RESULTS

A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant.

CONCLUSIONS

The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

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

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

Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes

Background

The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death.

Methods

200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model.

Results

59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures.

Conclusions

Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.

Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?

Background

Women have higher utilization of “do not attempt resuscitation” (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear.

Methods and Results

We identified 71 820 patients with return of spontaneous circulation (ROSC) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10–1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99–1.02]; P=0.74) was appreciated.

Conclusions

In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.

Association Between the Communication Skills of Physicians and the Signing of Do-Not-Resuscitate Consent for Terminally Ill Patients in Emergency Rooms (Cross-Sectional Study)

Background

The signing of do-not-resuscitate (DNR) consent is mandatory in providing a palliative approach in the end-of-life care for the terminally ill patients and requires an effective communication between the physician and the patients or their family members. This study aimed to investigate the association between the communication skills of physicians who participated in the SHARE (supportive environment, how to deliver the bad news, additional information, reassurance, and emotional support) model course on the patient notification and the signing of do-not-resuscitate (DNR) consent by the terminally ill patients at emergency rooms.

Methods

Between May 1, 2017 and April 30, 2018, a total of 109 terminally ill patients were enrolled in this study, of which 70 had signed a DNR and 39 had not. Data regarding the patients’ medical records, a questionnaire survey completed by family members, and patient observation forms were used for the assessment of physicians’ communication skills during patient notification. The observation form was designed based on the SHARE model. A multivariate logistic regression model was applied to identify the independent significant factors of the patient and family member variables as well as the four main components of the observation form.

Results

The results revealed that knowing how to convey bad news and providing reassurance and emotional support were significantly correlated with a higher rate of signing DNR consent. Additionally, physician-initiated discussion with family members and a predicted limited life expectancy were negative independent significant factors for signing DNR consent.

Conclusion

This study revealed that good communication skills help to increase the signing of DNR consent. The learning of such skills from attendance of the SHARE model course is encouraged for the physicians in the palliative care of terminally ill patients in an emergency room.

Epidemiologic Trends of Adoption of Do-Not-Resuscitate Status After Pediatric In-Hospital Cardiac Arrest

OBJECTIVES

To evaluate the prevalence of do-not-resuscitate status, assess the epidemiologic trends of do-not-resuscitate status, and assess the factors associated with do-not-resuscitate status in children after in-hospital cardiac arrest using large, multi-institutional data.

DESIGN

Generalized estimating equations logistic regression model was used to evaluate the trends of do-not-resuscitate status and evaluate the factors associated with do-not-resuscitate status after cardiac arrest.

SETTING

American Heart Association's Get With the Guidelines-Resuscitation Registry.

PATIENTS

Children (< 18 yr old) with an index in-hospital cardiac arrest and greater than or equal to 1 minute of documented chest compressions were included (2006-2015). Patients with no return of spontaneous circulation after cardiac arrest were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In total, 8,062 patients qualified for inclusion. Of these, 1,160 patients (14.4%) adopted do-not-resuscitate status after cardiac arrest. We found low rates of survival to hospital discharge among children with do-not-resuscitate status (do-not-resuscitate vs no do-not-resuscitate: 6.0% vs 69.7%). Our study found that rates of do-not-resuscitate status after cardiac arrest are highest in children with Hispanic ethnicity (16.4%), white race (15.0%), and treatment at institutions with larger PICUs (> 50 PICU beds: 17.8%) and at institutions located in North Central (17.6%) and South Atlantic/Puerto Rico (17.1%) regions of the United States. Do-not-resuscitate status was more common among patients with more preexisting conditions, longer duration of cardiac arrest, greater than 1 cardiac arrest, and among patients requiring extracorporeal cardiopulmonary resuscitation. We also found that trends of do-not-resuscitate status after cardiac arrest in children are decreasing in recent years (2013-2015: 13.8%), compared with previous years (2006-2009: 16.0%).

CONCLUSIONS

Patient-, hospital-, and regional-level factors are associated with do-not-resuscitate status after pediatric cardiac arrest. As cardiac arrest might be a signal of terminal chronic illness, a timely discussion of do-not-resuscitate status after cardiac arrest might help families prioritize quality of end-of-life care.

The effect of patient code status on surgical resident decision making: A national survey of general surgery residents

BACKGROUND

Multiple studies have demonstrated that, compared with their full code counterparts, patients with do-not-resuscitate or do-not-intubate status have higher in-hospital and postdischarge mortality than predicted by clinical characteristics alone. We sought to determine whether patient code status affects surgical resident decision making.

METHODS

We created an online survey that consisted of 4 vignettes, followed by 10 questions regarding decisions on possible diagnostic and therapeutic interventions. All program directors of Accreditation Council for Graduate Medical Education-accredited general surgery residencies were randomized to receive 1 of 2 survey versions that differed only in the code status of the patients described, with requests to distribute the survey to their residents. Responses to each question were based on a Likert scale.

RESULTS

A total of 194 residents completed the survey, 51% of whom were women, and all years of surgical residency were represented. In all vignettes, patient code status influenced perioperative medical decisions, ranging from initiation of dialysis to intensive care unit transfer. In 2 vignettes, it affected decisions to proceed with indicated emergency operations.

CONCLUSION

When presented with patient scenarios pertaining to clinical decision making, surgical residents tend to assume that patients with a do-not-resuscitate or do-not-intubate code status would prefer to receive less aggressive care overall. As a result, the delivery of appropriate surgical care may be improperly limited unless a patient's goals of care are explicitly stated. It is important for surgical residents to understand that a do-not-resuscitate or do-not-intubate code status should not be interpreted as a "do-not-treat" status.

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

OBJECTIVE

The aim of this study was to determine whether do-not-resuscitate (DNR) orders affect outcomes in patients with sepsis admitted to intensive care unit (ICU).

DESIGN

This is a retrospective observational study.

PARTICIPANTS

We enrolled 796 consecutive adult intensive care patients at Kaohsiung Chang Gung Memorial Hospital, a 2700-bed tertiary teaching hospital in southern Taiwan. A total of 717 patients were included.

MAIN MEASURES

Clinical factors such as age, gender and other clinical factors possibly related to DNR orders and hospital mortality were recorded.

KEY RESULTS

There were 455 patients in the group without DNR orders and 262 patients in the group with DNR orders. Within the DNR group, patients were further grouped into early (orders signed on intensive care day 1, n=126) and late (signed after day 1, n=136). Patients in the DNR group were older and more likely to have malignancy than the group without DNR orders. Mortality at days 7, 14 and 28, as well as intensive care and hospital mortality, were all worse in these patients even after propensity-score matching. There were higher Charlson Comorbidity Index in the emergency room, but better outcomes in those with early-DNR orders compared with late-DNR orders.

CONCLUSIONS

DNR orders may predict worse outcomes for patients with sepsis admitted to medical ICUs. The survival rate in the early-DNR order group was not inferior to the late-DNR order group.

The training in SHARE communication course by physicians increases the signing of do-not-resuscitate orders for critical patients in the emergency room (cross-sectional study)

BACKGROUND

Communication skills may be an important skill for the front-line emergency physicians.

AIM

This study aimed to investigate the effect of training in a SHARE communication course by emergency physicians on patient notification and signing of do-not-resuscitate (DNR) orders for critical patients in the emergency room.

DESIGN

From a total of 29 attending physicians in the emergency department, 19 physicians had been trained in the SHARE communication course. An observation form designed based on the SHARE training was completed by two observers who noted the communication process between physicians and patients and family members during patient notification and signing a DNR order. To assess the influence of physicians trained in a SHARE communication course on the signing of DNR orders, a propensity score-matched population was created to reduce the potential selection bias of patients and family members.

SETTING

Level 1 trauma medical center in southern Taiwan.

RESULTS

There were 145 individuals enrolled in the study, of which 93 signed the DNR order, and 52 did not sign it. Analysis from 23 matched pairs from this population revealed that significantly more family members would sign a DNR order if the physician had been trained in the SHARE communication course than when they did not receive this training (78.3% vs. 39.1%, respectively, p = 0.017). The overall score of the observation form for physicians was higher in those individuals who had signed a DNR order than in those who did not sign it (29.48 ± 3.72 vs. 26.13 ± 3.52, respectively, p = 0.003), especially when the physician had chosen a quiet environment (1.35 ± 0.65 vs. 0.87 ± 0.69, respectively, p = 0.020), understood the patient's wishes and confirmed them (1.78 ± 0.42 vs. 1.30 ± 0.70, respectively, p = 0.008), and expressed concern (1.48 ± 0.79 vs. 0.96 ± 0.77, respectively, p = 0.028). In addition, a feedback survey about the feelings experienced by these physicians during the process of patient notification did not reveal a significant difference during the communication with those who had or had not signed DNR orders.

CONCLUSION

The training in a SHARE communication course can improve the communication skills of emergency physicians in patient notification and signing of DNR orders for critical patients.

Sex Differences in "Do Not Attempt Resuscitation" Orders After Out-of-Hospital Cardiac Arrest and the Relationship to Critical Hospital Interventions

PURPOSE

Women who experience out-of-hospital cardiac arrest have similar rates of survival to hospital admission as men; however, women are less likely to survive to hospital discharge. We hypothesized that women would have higher rates of "do not attempt resuscitation" (DNAR) orders and that this order would be associated with lower use of aggressive interventions.

METHODS

We identified adult hospital admissions with a diagnosis of cardiac arrest (ICD-9 427.5) from the 2010 California State Inpatient Dataset. Multivariable logistic regression was used to test the association between patient sex and a DNAR order within the first 24 h of admission, adjusting for patient demographic characteristics and comorbid medical conditions. In secondary analysis, procedures performed after establishment of DNAR order and survival to hospital discharge were compared by sex.

FINDINGS

We analyzed 6562 patients (44% women, 56% men) who experienced out-of-hospital cardiac arrest and survived to hospital admission. In unadjusted analysis, more women than men had establishment of a DNAR order during the first 24 h of admission (23.4% versus 19.3%; P < 0.01). After adjusting for age, race, and comorbid conditions, women remained significantly more likely to have a DNAR order established during the first 24 h of their hospital admission after cardiac arrest compared with men (odds ratio = 1.23; 95% CI, 1.09-1.40). No sex difference was found in procedures used after DNAR order was established.

IMPLICATIONS

Female survivors of cardiac arrest are significantly more likely than men to have a DNAR order established within the first 24 h of in-hospital treatment. The establishment of a DNAR order is associated with patients undergoing fewer procedures than individuals who do not have a DNAR order established. Given that patients who have a DNAR order receive less-aggressive intervention after arrest, it is possible that an early DNAR order may contribute to sex differences in survival to hospital discharge.

A Mixed-Methods Exploration of Pediatric Intensivists' Attitudes toward End-of-Life Care in Vietnam

Background: Although the need for palliative care is gaining recognition in Southeast Asia, knowledge about how decisions are made for children near the end of life remains sparse. Objective: To explore pediatric intensivists' attitudes and practices surrounding end-of-life care in Vietnam. Methods: This is a mixed-methods study conducted at a tertiary pediatric and neonatal intensive care unit in Hanoi. Physicians and nurses completed a quantitative survey about their views on end-of-life care. A subset of these providers participated in semistructured interviews on related topics. Analysis of surveys and interviews were conducted. Results were triangulated. Results: Sixty-eight providers (33 physicians and 35 nurses) completed the quantitative survey, and 18 participated in interviews. Qualitative data revealed three overarching themes with numerous subthemes and supporting quotations. The first theme was factors influencing providers' decision-making process to escalate or withdraw treatment. Quantitative data showed that 40% of providers valued the family's ability to pay to continue life-sustaining treatment. Second, communication dynamics in decision making were highlighted; 72% of providers would be willing to override a family's wishes to withdraw life-sustaining treatment. Third, provider perceptions of death varied, with 68% regarding their patients' deaths as a personal failure. Conclusions: We elicited and documented how pediatric intensivists in Vietnam currently think about and provide end-of-life care. These findings indicate a need to strengthen palliative care training, increase family involvement in decision making, implement standardized and official do-not-resuscitate documentation, and expand pediatric hospice services at the individual, hospital, and national levels in Vietnam.

Variation in outcomes among 24/7 percutaneous coronary intervention centres for patients resuscitated from out-of-hospital cardiac arrest

BACKGROUND

Patients treated at 24/7 percutaneous coronary intervention (PCI) centres following out-of-hospital cardiac arrest (OHCA) have better outcomes than those treated at non-24/7 PCI centres. However, variation in outcomes between 24/7 PCI centres is not well studied.

OBJECTIVES

To evaluate variation in outcomes among 24/7 PCI centres and to assess stability of 24/7 PCI centre performance.

METHODS

Adult patients in the California Office of Statewide Health Planning and Development Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest admitted to a 24/7 PCI centre from 2011 to 2015 were included. Primary outcome was good neurologic recovery at hospital discharge. Secondary outcomes were survival to hospital discharge, cardiac catheterisation, and DNR orders within 24 h. Data were analysed using mixed effects logistic regression models. Hospitals were ranked each year and overall.

RESULTS

Of 27,122 patients admitted to 128 24/7 PCI centres, 41% (11,184) survived and 27% (7188) had good neurologic recovery. Adjusted rates of good neurologic recovery (18%-39%; p,0.001), survival (32%-51%; p < 0.0001), cardiac catheterisation (11%-49%; p < 0.0001) and DNR orders within 24 h (4.8%-49%; p < 0.0001) varied between 24/7 PCI centres. For the 26 hospitals with mean good neurologic rankings in the top or bottom tenth during 2011-2013, 14 (54%) remained in their respective tenth for 2014-2015.

CONCLUSION

Significant variation exists between 24/7 PCI centres in good neurologic recovery following OHCA and persists over time. Future studies should evaluate hospital-level factors that contribute to these differences in outcomes between 24/7 PCI centres.

Timing and modes of death after pediatric out-of-hospital cardiac arrest resuscitation

AIM

To determine the timing and modes of death of children admitted to a pediatric critical care unit (PICU) of a tertiary care center after an out-of-hospital cardiac arrest (OHCA).

METHODS

This is a retrospective descriptive study at a tertiary care PICU of all consecutive patients <18 years old who received ≥1 min of chest compressions, had return of spontaneous circulation (ROSC) for ≥20 min, and were admitted to the PICU after an OHCA. Modes of death were classified as brain death (BD), withdrawal due to neurologic prognosis (W/D-neuro), withdrawal for refractory circulatory failure (W/D-RCF), and re-arrest without ROSC (RA).

RESULTS

191 consecutive patients were admitted to the PICU from February 2005 to May 2013 after an OHCA. Eighty-six(45%) patients died prior to discharge: BD in 47%(40/86), W/D-neuro in 34%(29/86), W/D-RCF in 10%(9/86), and RA in 9%(8/86). Time to death was longer for patients with W/D-neuro: 4 days [1, 5] and BD 4 days [1, 5](p < 0.01) as opposed to those with W/D-RCF (1 day[1, 2]) and RA(1 day[0.5, 1]). Of patients who underwent W/D-neuro, 9/29(31%) died within 3 days of PICU admission and 20/29(69%) ≥3 days. Of patients who died after W/D-neuro, 12/29(41%) received therapeutic hypothermia, 27/29(93%) underwent EEG monitoring, 21/29(72%) had a brain CT, and 13/29(45%) had a brain MRI. All MRIs showed signs of hypoxic-ischemic injury.

CONCLUSION

Neurologic injury was the most common mode of death post-resuscitation care OHCA after in a tertiary care center PICU. Neurologic prognostication impacts the outcome of a large proportion of patients after OHCA, and further studies are warranted to improve its reliability.

End-of-life decisions in emergency patients: prevalence, outcome and physician effect

BACKGROUND

End-of-life decisions (EOLD) represent potentially highly consequential decisions often made in acute situations, such as 'do not attempt resuscitation' (DNAR) choices at emergency presentation.

AIM

We investigated DNAR decisions in an emergency department (ED) to assess prevalence, associated patient characteristics, potential medical and economic consequences and estimate contributions of patients and physicians to DNAR decisions.

DESIGN

Single-centre retrospective observation, including ED patients with subsequent hospitalization between 2012 and 2016. Primary outcome was a DNAR decision and associated patient characteristics. Secondary outcomes were mortality, admission to intensive care unit and use of resources.

METHODS

Associations between DNAR and patient characteristics were analysed using logistic mixed effects models, results were reported as odds ratios (OR). Median odds ratios (MOR) were used to estimate patient and physician contributions to variability in DNAR.

RESULTS

Patients of 10 458 were attended by 315 physicians. DNAR was the choice in 23.3% of patients. Patients' characteristics highly associated with DNAR were age (OR = 4.0, 95% CI = 3.6-4.3) and non-trauma presentation (OR = 2.3, 95% CI = 1.9-2.9). In-hospital mortality was significantly higher (OR = 5.4, CI = 4.0-7.3), and use of resources was significantly lower (OR = 0.7, CI = 0.6-0.8) in patients choosing DNAR. There was a significant effect on DNAR by both patient (MOR = 1.8) and physician (MOR = 2.0).

CONCLUSIONS

DNAR choices are common in emergency patients and closely associated with age and non-trauma presentation. Mortality was significantly higher, and use of resources significantly lower in DNAR patients. Evidence of a physician effect raises questions about the choice autonomy of emergency patients in the process of EOLD.

A five-year retrospective study of out-of-hospital cardiac arrest in a north-east Italian urban area

BACKGROUND

The reporting and analysing of data of out-of-hospital cardiac arrests encourages the quality improvement of the emergency medical services. For this reason, the establishment of a sufficiently large patient database is intended to allow analysis of resuscitation treatments for out-of-hospital cardiac arrests and performances of different emergency medical services.

AIMS

The aim of this study was to describe the demographics, characteristics, outcomes and determinant factors of survival for patients who suffered an out-of-hospital cardiac arrest.

METHODS

this was a retrospective study including all out-of-hospital cardiac arrest cases treated by the emergency medical service in the district of Udine (Italy) from 1 January 2010-31 December 2014.

RESULTS

A total of 1105 out-of-hospital cardiac arrest patients were attended by the emergency medical service. Of these, 489 (44.2%) underwent cardiopulmonary resuscitation, and return of spontaneous circulation was achieved in 142 patients (29%). There was a male predominance overall, and the main age was 72.6 years (standard deviation 17.9). Cardiopulmonary resuscitation before emergency medical service arrival was performed on 62 cases (44%) in the return of spontaneous circulation group, and on 115 cases (33%) in the no return of spontaneous circulation group ( p<0.024). Among the 142 cases of return of spontaneous circulation, 29 (5.9%) survived to hospital discharge. There was a smaller likelihood of return of spontaneous circulation when patients were female (odds ratio 0.61, 0.40-0.93). Patients who had an out-of-hospital cardiac arrest with an initial shockable rhythm (odds ratio 6.33, 3.86-10.39) or an age <60 years (odds ratio 2.91, 1.86-4.57) had a greater likelihood of return of spontaneous circulation. In addition, bystander cardiopulmonary resuscitation (odds ratio 1.56, 1.04-2.33) was associated with an increased chance of return of spontaneous circulation.

CONCLUSION

The incidence of out-of-hospital cardiac arrest and survival rate lies within the known range. A wider database is necessary to achieve a better knowledge of out-of-hospital cardiac arrest and to drive future investments in the healthcare system.

Sex, race, and insurance status differences in hospital treatment and outcomes following out-of-hospital cardiac arrest

BACKGROUND

Sex, race, and insurance status are associated with treatment and outcomes in several cardiovascular diseases. These disparities, however, have not been well-studied in out-of-hospital cardiac arrest (OHCA).

OBJECTIVE

Our objective was to evaluate the association of patient sex, race, and insurance status with hospital treatments and outcomes following OHCA.

METHODS

We studied adult patients in the 2011-2015 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest (ICD-9-CM 427.5). Insurance status was classified as private, Medicare, and Medi-Cal/government/self-pay. Our primary outcome was good neurologic recovery at hospital discharge, which was determined by discharge disposition. Secondary outcomes were survival to hospital discharge, treatment at a 24/7 percutaneous coronary intervention (PCI) center, "do not resuscitate" orders within 24 h of admission, and cardiac catheterization during hospitalization. Data were analyzed with hierarchical multiple logistic regression models.

RESULTS

We studied 38,163 patients in the OSHPD database. Female sex, non-white race, and Medicare insurance status were independently associated with worse neurologic recovery [OR 0.94 (0.89-0.98), 0.93 (0.88-0.98), and 0.85 (0.79-0.91), respectively], lower rates of treatment at a 24/7 PCI center [OR 0.89 (0.85-0.93), 0.88 (0.85-0.93), and 0.87 (0.82-0.94), respectively], and lower rates of cardiac catheterization [OR 0.61 (0.57-0.65), 0.90 (0.84-0.97), and 0.44 (0.40-0.48), respectively]. Female sex, white race, and Medicare insurance were associated with DNR orders within 24 h of admission [OR 1.16 (1.10-1.23), 1.14 (1.07-1.21), and 1.25 (1.15-1.36), respectively].

CONCLUSIONS

Sex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.

Out-of-hospital cardiac arrest with Do-Not-Resuscitate orders signed in hospital: Who are the survivors?

BACKGROUND

Signing Do-Not-Resuscitate orders is an important element contributing to a worse prognosis for out-of-hospital cardiac arrest (OHCA). However, our data showed that some of those OHCA patients with Do-Not-Resuscitate orders signed in hospital survived to hospital discharge, and even recovered with favorable neurological function. In this study, we described their clinical features and identified those factors that were associated with better outcomes.

METHODS

A retrospective, observational analysis was performed on all adult non-traumatic OHCA who were enrolled in the Resuscitation Outcomes Consortium (ROC) PRIMED study but signed Do-Not-Resuscitate orders in hospital after admission. We reported their demographics, characteristics, interventions and outcomes of all enrolled cases. Patients surviving and not surviving to hospital discharge, as well as those who did and did not obtain favorable neurological recovery, were compared. Logistic regression models assessed those factors which might be prognostic to survival and favorable neurological outcomes at discharge.

RESULTS

Of 2289 admitted patients with Do-Not-Resuscitate order signed in hospital, 132(5.8%) survived to hospital discharge and 28(1.2%) achieved favorable neurological recovery. Those factors, including witnessed arrest, prehospital shock delivered, Return of Spontaneous Circulation (ROSC) obtained in the field, cardiovascular interventions or procedures applied, and no prehospital adrenaline administered, were independently associated with better outcomes.

CONCLUSIONS

We suggest that some factors should be taken into considerations before Do-Not-Resuscitate decisions are made in hospital for those admitted OHCA patients.

Validation of an ICD code for accurately identifying emergency department patients who suffer an out-of-hospital cardiac arrest

AIM

International classification of disease (ICD-9) code 427.5 (cardiac arrest) is utilized to identify cohorts of patients who suffer out-of-hospital cardiac arrest (OHCA), though the use of ICD codes for this purpose has never been formally validated. We sought to validate the utility of ICD-9 code 427.5 by identifying patients admitted from the emergency department (ED) after OHCA.

METHODS

Adult visits to a single ED between January 2007 and July 2012 were retrospectively examined and a keyword search of the electronic medical record (EMR) was used to identify patients. Cardiac arrest was confirmed; and ICD-9 information and location of return of spontaneous circulation (ROSC) were collected. Separately, the EMR was searched for patients who received ICD-9 code 427.5. The kappa coefficient (κ) was calculated, as was the sensitivity and specificity of the code for identifying OHCA.

RESULTS

The keyword search identified 1717 patients, of which 385 suffered OHCA and 333 were assigned the code 427.5. The agreement between ICD-9 code and cardiac arrest was excellent (κ = 0.895). The ICD-9 code 427.5 was both specific (99.4%) and sensitive (86.5%). Of the 52 cardiac arrests that were not identified by ICD-9 code, 33% had ROSC before arrival to the ED. When searching independently on ICD-9 code, 347 patients with ICD-9 code 427.5 were found, of which 320 were "true" arrests. This yielded a positive predictive value of 92% for ICD-9 code 427.5 in predicting OHCA.

CONCLUSIONS

ICD-9 code 427.5 is sensitive and specific for identifying ED patients who suffer OHCA with a positive predictive value of 92%.

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.

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.

Patient Outcomes After Palliative Care Consultation Among Patients Undergoing Therapeutic Hypothermia

OBJECTIVES

To compare the clinical outcomes of patients who did and did not receive palliative care consultation among those who experienced out-of-hospital cardiac arrest and underwent therapeutic hypothermia.

METHODS

We identified patients at a single academic medical center who had undergone therapeutic hypothermia after out-of-hospital cardiac arrest between 2009 and 2013. We performed a retrospective chart review for demographic data, hospital and critical care length of stay, and clinical outcomes of care.

RESULTS

We reviewed the charts of 62 patients, of which 35 (56%) received a palliative care consultation and 27 (44%) did not. Palliative care consultation occurred an average of 8.3 days after admission. Patients receiving palliative care consultation were more likely to have a do-not-resuscitate (DNR) order placed (odds ratio: 2.3, P < .001). The mean length of stay in the hospital was similar for patients seen by palliative care or not (16.7 vs 17.1 days, P = .90). Intensive care length of stay was also similar (11.3 vs 12.6 days, P = .55).

CONCLUSIONS

Palliative care consultation was underutilized and utilized late in this cohort. Palliative consultation was associated with DNR orders but did not affect measures of utilization such as hospital and intensive care length of stay.

Room for improvement: An examination of advance care planning documentation among gynecologic oncology patients

OBJECTIVES

The goals of this study were: (1) to evaluate patients' knowledge regarding advance directives and completion rates of advance directives among gynecologic oncology patients and (2) to examine the association between death anxiety, disease symptom burden, and patient initiation of advance directives.

METHODS

110 gynecologic cancer patients were surveyed regarding their knowledge and completion of advance directives. Patients also completed the MD Anderson Symptom Inventory (MDASI) scale and Templer's Death Anxiety Scale (DAS). Descriptive statistics were utilized to examine characteristics of the sample. Fisher's exact tests and 2-sample t-tests were utilized to examine associations between key variables.

RESULTS

Most patients were white (76.4%) and had ovarian (46.4%) or uterine cancer (34.6%). Nearly half (47.0%) had recurrent disease. The majority of patients had heard about advance directives (75%). Only 49% had completed a living will or medical power of attorney. Older patients and those with a higher level of education were more likely to have completed an advance directive (p<0.01). Higher MDASI Interference Score (higher symptom burden) was associated with patients being less likely to have a living will or medical power of attorney (p=0.003). Higher DAS score (increased death anxiety) was associated with patients being less likely to have completed a living will or medical power of attorney (p=0.03).

CONCLUSION

Most patients were familiar with advance directives, but less than half had created these documents. Young age, lower level of education, disease-related interference with daily activities, and a higher level of death anxiety were associated with decreased rates of advance directive completion, indicating these may be barriers to advance care planning documentation. Young patients, less educated patients, patients with increased disease symptom burden, and patients with increased death anxiety should be targeted for advance care planning discussions as they may be less likely to engage in advance care planning.

Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis

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.

Decision Aids and Shared Decision-Making in Neurocritical Care: An Unmet Need in Our NeuroICUs

Improved resuscitation methods and advances in critical care have significantly increased the survival of patients presenting with devastating brain injuries compared to prior decades. After the patient's stabilization phase, families and patients are faced with "goals-of-care" decisions about continuation of aggressive intensive care unit care or comfort care only (CMO). Highly varying rates of CMO between centers raise the question of "self-fulfilling prophecies." Disease severity, the physician's communication and the family's understanding of projected outcomes, their uncertainties, complication risks with continued care, physician bias, and the patient's and surrogate's wishes and values all influence a CMO decision. Disease-specific decision support interventions, decision aids (DAs), may remedy these issues in the neurocritical care unit, potentially leading to better-informed and less-biased goals-of-care decisions in neurocritically ill patients, while increasing decision knowledge, confidence, and realistic expectations and decreasing decisional conflict and regret. Shared decision-making (SDM) is a collaborative process that enhances patients' and proxies' understanding about prognosis, encourages them to actively weigh the risks and benefits of a treatment, and considers the patient's preferences and values to make better decisions. DAs are SDM tools, which have been successfully implemented for many other conditions to assist difficult decision-making. In this article, we summarize the purposes of SDM, the derivation of DAs, and their potential application in neurocritical care.

Impact of end-of-life discussions on the reduction of Latino/non-Latino disparities in do-not-resuscitate order completion

BACKGROUND

Compared with non-Latino, white patients with advanced cancer, Latino patients with advanced cancer are less likely to sign do-not-resuscitate (DNR) orders, which is a form of advance care planning associated with better quality of life at the end of life (EOL). Latinos' completion of DNR orders may be more sensitive to clinical discussions regarding EOL care. The current study examined differences between Latino and white terminally ill patients with cancer with regard to the association between EOL discussions and DNR order completion.

METHODS

A total of 117 participants with advanced cancer (61 of whom were Latino and 56 of whom were non-Latino white individuals) were recruited between 2002 and 2008 from Parkland Hospital (a public hospital in Dallas, Texas) as part of the Coping with Cancer study, which is a large, multiinstitutional, prospective cohort study of patients with advanced cancer that is designed to examine social and psychological influences on EOL care. In structured interviews, patients reported if they had EOL discussions with their physicians, and if they completed DNR orders.

RESULTS

The association between EOL discussions and DNR order completion was significantly greater in Latino compared with white patients, adjusting for potential confounds (interaction adjusted odds ratio, 6.64; P = .041). Latino patients who had an EOL discussion were >10 times more likely (adjusted odds ratio, 10.91; P = .001) to complete a DNR order than those who had not, and were found to be equally as likely to complete a DNR order as white patients.

CONCLUSIONS

Differences in the impact of EOL discussions on DNR order completion may explain Latino/non-Latino ethnic disparities in DNR order completion in EOL care, and point to a means to eliminate those disparities. Cancer 2016;122:1749-56. © 2016 American Cancer Society.

Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest

IMPORTANCE

After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.

OBJECTIVE

To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis.

DESIGN, SETTING, AND PARTICIPANTS

Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (ie, without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined.

EXPOSURES

Do-not-resuscitate orders within 12 hours of ROSC.

MAIN OUTCOMES AND MEASURES

Likelihood of favorable neurological survival.

RESULTS

Overall, 5944 (22.6% [95% CI, 22.1%-23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P < .05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (P for both trends <.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI, 29.9%-31.1%]) than it was for those with DNR orders (1.8% [95% CI, 1.6%-2.0%]). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis.

CONCLUSIONS AND RELEVANCE

Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including those with the best prognosis.

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.