Patient and Hospital-Level Characteristics Associated with the Use of Do-Not-Resuscitate Orders in Patients Hospitalized for Sepsis

Abstract

BACKGROUND: Identifying factors associated with donot-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed. METHODS: A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders. RESULTS: Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order. CONCLUSION: Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .KEY WORDS: end-of-life care; healthcare delivery; epidemiology.

Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes

“…Consistent with the published literature on the subject, [11][12][13] most patients in this cohort had a late DNR. As others have published, older patients, those with more comorbidities, and those who were white were more likely to have an early DNR [4,[28][29][30] Older patients and those with comorbidities may have more opportunity for discussion with their doctors and families about advanced directives and may be more likely to have accepted their own mortality. [31,32] The racial disparity may be, in part, due to distrust of the health care system among patients who are members of racial or ethnic minority groups [33][34][35] who may perceive DNR orders as denying patients life-saving medical care.…”

“…Cardiopulmonary Resuscitation (CPR) was introduced to clinical practice in the 1960's [1] and became a default treatment for patients with cardiac arrest regardless of their underlying injury or disease. [2] Since that time, however, it has become clear that CPR does not necessarily benefit patients who are terminally ill. [3][4][5] Do-Not-Resuscitate (DNR) orders are an alternative for patients at the end of life, [3] to prevent receipt of nonbeneficial procedures (e.g. CPR) and unnecessary suffering when patients are imminently dying.…”

High Mortality in Severe Sepsis and Septic Shock Patients with Do-Not-Resuscitate Orders in East Asia

“…Our findings were in consistent with those from Western studies. [ 37 , 38 ] Nonetheless, the study design did not allow us to assess the effects of dissimilarities among institutions and healthcare systems on the DNR status. Based on prior studies, we do expect a wide variation in the DNR decisions within and between countries.…”

“…Based on prior studies, we do expect a wide variation in the DNR decisions within and between countries. [ 8 , 10 , 36 , 38 ]…”

Factors Underlying Racial Disparities in Sepsis Management

“…Nonwhite sepsis patients, while more often presenting with increased organ dysfunction, are younger and could make a full recovery [14,16,23,50]. Black patients are also less likely to receive do-not-resuscitate orders in the ICU, so they more frequently undergo life-sustaining treatments during hospitalization regardless of previous comorbidities or functional status [66,67].…”