Do‐Not‐Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score–Matched Analysis

Patel, Krunalkumar; Sinvani, Liron; Patel, Vidhi; Kozikowski, Andrzej; Smilios, Christopher; Akerman, Meredith; Kiszko, Kinga; Maiti, Sutapa; Hajizadeh, Negin; Wolf‐Klein, Gisele; Pekmezaris, Renée

doi:10.1111/jgs.15347

Cited by 23 publications

(35 citation statements)

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“…[18] Previous studies reported a strong association between the presence of a DNR order and mortality. [17] In our study, we found that signing DNR orders on the day of the patients' death was the most common (68.7%). Signing DNR order increased as death approached.…”

Section: Discussionmentioning

confidence: 58%

“…However, in Europe and North America, older patients prefer to make their final DNR directives. [17,29] The possible reasons are few ADs, [30] no anticipation about end-of-life decisions before admission in ED, and conversations between physicians and family surrogates at the last admission. Because of the lack of ADs, family members need to express patients' wishes concerning their end-of-life preferences.…”

Section: Discussionmentioning

confidence: 99%

“…[11,16] Patients consenting to DNR were often able to avoid futile examination and invasive rescue measures, to alleviate suffering and maintain their dignity. [17] Signing a DNR consent form is an important medical decision-making process; early initiation of discussions can improve end-of-life care and reduce futile treatments in EDs. [11] In China, many families object to revealing about an incurable diagnosis or poor disease prognosis to patients, which may impede the end-of-life care-related decisions.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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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 infl uenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confi dence 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.

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Section: Discussionmentioning

confidence: 58%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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“…However, a patient's do-notresuscitate (DNR) status is not included in risk adjustment despite the greater severity of illness and mortality risk among patients with DNR status present on admission (POA). [7][8][9][10] Evidence is limited on the association between the prevalence of POA DNR status and the riskstandardized outcome rates at hospitals. Although hospital-level prevalence of POA DNR status varies, the DNR status of patients is documented reliably enough for inclusion in risk-standardization models and analyses, suggesting that adjustment for patient-level DNR status improves the predictive accuracy of 30-day RSMRs for AMI, HF, and pneumonia.…”

Section: Introductionmentioning

confidence: 99%

Association of Do-Not-Resuscitate Patient Case Mix With Publicly Reported Risk-Standardized Hospital Mortality and Readmission Rates

et al. 2020

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IMPORTANCE The Centers for Medicare and Medicaid Services's (CMS's) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings. OBJECTIVE To identify the association between hospital-level DNR prevalence and conditionspecific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis. EXPOSURES Present-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions. MAIN OUTCOMES AND MEASURES Hospital-level 30-day RSMRs and RSRRs for 5 conditionspecific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no). RESULTS Included in the study were 4 884 237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2 608 182 women [53.4%]) and 4 450 378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P < .001). The inverse was true among the readmission cohorts, with the highest quintiles of DNR prevalence exhibiting the lowest RSRRs (eg, AMI: 15.

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“…1,[9][10][11][12][13][14][15][16] No DNR order or a late one can signal suboptimal physicianpatient EoL care communication, leading to more lifesustaining treatments (LSTs) 10,14,17,18 and poor EoL care quality. [17][18][19] Timely, adequate EoL care discussions cultivate patients' accurate prognostic awareness (PA), 20 allowing them to realistically appraise their illness/life expectancy and come to terms with their forthcoming death, thereby increasing the likelihood of issuing a DNR order. 21,22 However, physicians worldwide tend to discuss DNR options late; they commonly present DNR options when curative anticancer treatments and nonpalliative measures fail 23,24 (including failure of CPR to save a patient's life).…”

Section: Introductionmentioning

confidence: 99%

Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

Wen

Chen

Chou

et al. 2020

Journal of the National Comprehensive Cancer Network

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Background: Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders. Patients and Methods: Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling. Results: At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036–4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989–89.786; P=.008). Both arms issued DNR orders close to death (median, 5–6 days before death). Conclusions: Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846

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Do‐Not‐Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score–Matched Analysis

Abstract: Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.

Cited by 23 publications

References 20 publications

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

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

Association of Do-Not-Resuscitate Patient Case Mix With Publicly Reported Risk-Standardized Hospital Mortality and Readmission Rates

Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

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