Thursday, September 24, 2015

DNR orders adversely affect survival

Fendler TJ, Spertus JA, Kennedy KF, Chen LM, Perman SM, Chan PS; American Heart Association’s Get With the Guidelines–Resuscitation Investigators. Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest. JAMA. 2015 Sep 22-29;314(12):1264-71.

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.

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1 comment:

  1. When I came back to Mrs. B, her room was full of doctors and nurses; she was breathing very heavily and her heart was racing, so the staff was trying to control her pulse. I saw she was scared. I held her hand and asked her about her plans after discharge. I asked her about her daughter and grandkids. She could barely breathe but was eager to tell me. After a half hour, her heart went back to normal and things seemed under control.

    “Are you okay?” I asked.

    “I feel like dancing,” she replied.

    Before going home last night, I went to check on Mrs. B. one last time. She was doing well. She had heard she was going to be transferred to the cardiac unit so we could watch out for more arrhythmias like the ones she had experienced earlier in the day.

    “Doctor, I’m not going to come out of the hospital,” she said to me. I told her about a study in which patients who thought they wouldn’t come out of the hospital were more likely to die in the hospital than patients who thought they would. I made her tell me she’d come out of the hospital fine. Then I told her that I was going home, that I had only stopped to say goodbye...

    I know I did my best. I don’t regret one antibiotic I suggested for her, or one x-ray. But I’ll always regret not having told her last night how much I enjoyed getting to know her and how honored I felt that she trusted me so much.