Effect of a do-not-resuscitate order on the quality of care in acute heart failure patients: a single-center cohort study

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.

The Association Between Early Administration of Noninvasive Ventilation and Short-Term Outcome for Acute Heart Failure

Background Acute decompensated heart failure (ADHF) is a life-threatening disease that requires emergent intervention. Although noninvasive positive pressure ventilation (NPPV) is crucial for treating ADHF, the earliest time point for administering NPPV remains unknown. In this study, we hypothesized that early NPPV administration for patients with acute heart failure in the emergency department (ED) would lead to a better outcome. Methodology This is a single-center retrospective cohort study at an ED of a community hospital in Japan. The data were collected from consecutive patients who were administered NPPV for ADHF in the ED from April 2016 to September 2018. The primary exposure was the timing of NPPV administration (within 30 minutes versus over 30 minutes after arrival). The primary outcome was 30-day mortality. Results A total of 115 patients were included in this study. Overall, the median age was 78 (interquartile range [IQR] = 70-84 years), and 63 (54.9%) patients were male. The median time from the arrival at the ED to NPPV administration for the patients was 14 minutes (IQR = 8-30 minutes). Overall, 72% (83/115) of the patients were categorized as early administration group (<30 minutes). The total 30-day mortality was 7.0% (8/115), and the total tracheal intubation rate was 11% (13/115). Early NPPV administration for patients with ADHF was associated with lower 30-day mortality (3.6% vs. 16%; p = 0.04) and shorter length of oxygenation (four days vs. seven days; p < 0.01). Multivariate logistic regression test showed that 30-day mortality was significantly lower in the early treatment group (adjusted odds ratio = 0.19; 95% confidential interval = 0.04-0.90). Conclusions Although further investigation is needed, early NPPV administration for patients with ADHF in the ED was associated with lower 30-day mortality.

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.

Early DNR Order and Long-Term Prognosis Among Patients Hospitalized for Acute Heart Failure: Single-Center Cohort Study in Japan

Purpose

An early do-not-resuscitate (DNR) order is classified as such when it occurs within 24 hours of admission. Early DNR has been previously associated with in-hospital mortality among acute heart failure (AHF) patients and one-year mortality among patients discharged from ICU. Here, we investigate whether early DNR is associated with long-term mortality in AHF Japanese patients, by performing a retrospective cohort study.

Patients and Methods

We retrospectively investigated all patients with AHF, admitted to our hospital between April 2013 and March 2015, and survived to discharge. We obtained data on demographics, comorbidities, laboratory and echocardiography results, social background, DNR status, and outcomes (one-year death). The association of early DNR with one-year death was analyzed by multivariate logistic regression analysis.

Results

Among 370 survive to discharge patients, 48 (12%) were lost to follow up. We analyzed 322 patients. The median age was 74 years, and 80 (25%) had an early DNR order. Patients with a DNR order were older and displayed more activities of daily living (ADL)-dependence. Early DNR was associated with higher one-year mortality.

Conclusion

Early DNR was associated with one-year mortality among AHF patients. Further studies are necessary to investigate unmeasured factors associated with a worse prognosis related to early DNR among AHF patients.

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.