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

Abstract

BackgroundA do-not-resuscitate (DNR) order is reportedly associated with a decrease in performance measures, but it should not be applied to noncardiopulmonary resuscitation procedures. Good performance measures are associated with improvement in heart failure outcomes.AimTo analyze the influence of DNR order on performance measures of heart failure at our hospital, where lectures on DNR order are held every 3 months.DesignRetrospective cohort study.MethodsThe medical report of patients with acute heart failure who were admitted between April 2013 and March 2015 were retrospectively analyzed. We collected demographic data, information on the presence or absence of DNR order within 24 hours of admission, and inhospital mortality. Performance measures of heart failure, including assessment of cardiac function and discharge prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and beta-blocker for left ventricular systolic dysfunction and anticoagulant for atrial fibrillation, were collected and compared between groups with and without DNR orders.ResultsIn 394 total patients and 183 patients with left ventricular systolic dysfunction, 114 (30%) and 44 (24%) patients, respectively, had a DNR order. Patients with a DNR order had higher inhospital mortality. There were no significant differences between the two groups in terms of the four quality measures (left ventricular function assessment, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, and anticoagulant).ConclusionDNR orders did not affect performance measures, but they were associated with higher inhospital mortality among acute heart failure patients.

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

“…We reported that, under these circumstances, a DNR order did not affect QOC measures of AHF patients, such as the rate of echocardiography, initiation of beta-blocker and ACEi or ARB for heart failure with reduced EF, and administration of anticoagulant for heart failure with atrial fibrillation. 7 Therefore, in this study, a worse QOC was less likely to explain the higher rate of oneyear mortality among DNR patients although we could not exclude the possibility that a DNR order leads to withholding unmeasured care which improves prognosis, with a resultant higher rate of one-year mortality. Another potential explanation for early DNR-associated increase in mortality of heart failure patients is that physicians often consider the prognosis when discussing advance directives, including DNR wishes, with patients and/or families.…”

“…The inhospital mortality of acute heart failure was 6% in our cohort. 7 Although it is not an ideal time to initiate ACP among patients who have never discussed it in the past, it may be the best time from that point on, because AHF can be a life-threatening condition. Furthermore, discussing code status on admission reportedly decreased invasive procedures before death that cancer 25 and non-cancer inpatients in an advanced stage would like to avoid.…”

“…In these conditions, we have previously demonstrated that the presence of a DNR order did not worsen the QOC of heart failure patients. 7 Even though we did not evaluate the effect of an early DNR on clinical outcomes, patients with an early DNR order had higher inhospital mortality than those without. 7 In this situation, where the DNR order does not affect the QOC of AHF patients, we analyzed the same cohort to understand whether an early DNR order is a prognostic indicator of the one-year mortality among hospitalized AHF patients.…”

“…Lectures on advance care planning (ACP) and DNR orders are conducted quarterly, to ensure that the appropriate DNR order-related procedures are followed, as described elsewhere. 7 To prevent misuse of DNR orders and to ensure the patients' will and preference regarding CPR are respected, we use the code status order sheet shown in Figure 1. The precise discussion of ACP and code status are documented in the patient's progress note.…”

Do-Not-Resuscitate (DNR)

“…To effectively use and prevent misuse of DNR orders, health professional must be educated about DNR 19 .…”