Early Versus Late DNR Orders and its Predictors in a Saudi Arabian ICU

Abstract

Background Practices of Do-Not-Resuscitate (DNR) orders show discrepancies worldwide, but there are only few such studies from Saudi Arabia. Objective: To describe the practice of DNR orders in a Saudi Arabian tertiary care ICU. Methods: This retrospective study included all patients who died with a DNR order at the ICU of King Saud Medical City, Riyadh, Saudi Arabia, between January 1 to December 31, 2021. The percentage of early DNR (i.e., ≤48 hours of ICU admission) and late DNR (>48 hours) orders were determined and the variables between the two groups were compared. The determinants of late DNR were also investigated. Results: A total of 723 cases met the inclusion criteria, representing 14.9% of all ICU discharges and 63% of all ICU deaths during the study period. The late DNR group comprised the majority of the cases (78.3%), and included significantly more patients with acute respiratory distress syndrome (ARDS), community acquired pneumonia (CAP), acute kidney injury, and COVID-19, and significantly fewer cases of readmissions and malignancies. Septic shock lowered the odds of a late DNR (OR = 0.4, 95% CI: 0.2–0.9; P = 0.02), while ARDS (OR = 3.3, 95% CI: 2–5.4; P < 0.001), ischemic stroke (OR = 2.5, 95% CI: 1.1–5.4; P = 0.02), and CAP (OR = 2, 95% CI: 1.3–3.1; P = 0.003) increased the odds of a late DNR. Conclusion: There was a higher frequency of late DNR orders in our study compared to those reported in several studies worldwide. Cases with potential for a favorable outcome were more likely to have a late DNR order, while those with expected poorer outcomes were more likely to have an early DNR order. The discrepancies highlight the need for clearer guidelines to achieve consistency.

Practice and Predictors of Do-Not-Resuscitate Orders in a Tertiary-Care Intensive Care Unit in Saudi Arabia

“…In the current study, DNR orders were implemented in 13% of patients in the ICU. This rate is similar to what had been observed in other studies from different countries, including Saudi Arabia [ 17 , 18 ]. In an international study, a decision to withhold/withdraw life support during the ICU stay was reported in 1259/9524 (13%) patients [ 9 ].…”

“…We found that 55% of the deceased patients in the ICU had DNR orders before death. This rate is lower than that reported in other studies [ 18 , 25 ]. In a study of a large US sample of ICU patients (400129 admissions, 9891 deaths in the ICU), 91.3% of patients had DNR order before death [ 25 ].…”

“…A multicenter study in 40 ICUs in the United States found that 9% of admissions (1988–1990) had DNR orders written in the ICU (range, 1.5 to 22%) [ 17 ]. A study from an ICU in Saudi Arabia found that 14.9% of all ICU discharges (January 1 to December 31, 2021) had DNR orders [ 18 ]. However, the practice of DNR is more common in other ICUs.…”

Knowledge gaps, attitudes, and practices regarding end-of-life medical care among physicians in an academic medical center

“…On the other hand, 41% of the participating physicians ever had their patients have "advanced directive" or "living will". As indicated in other studies from Saudi Arabia [18,22,26], the majority of participating physicians are looking for additional learning materials and training related to DNR decision-making and ELMC as what is become standard practice to have a continuous professional development program for basic life support (BLS) is to have ELMC and DNR program. There is also a need for proper and new guidelines to deliver standardization of DNR practices and decision-making.…”

Diagnostic accuracy of ePOS score in predicting DNR labeling after ICU admission: A prospective observational study (ePOS-DNR)

“…[ 10 , 11 ] Additionally, there is no consensus on medical futility [ 12 ] or guidance on the practical aspects of the DNR process, such as objective criteria. [ 13 ]…”