Racial variation in the use of do-not-resuscitate orders

Abstract

OBJECTIVE:To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample. MEASUREMENTS:Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82-0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates. MAIN RESULTS:In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p Ͻ .001). Rates of orders were also lower ( p Ͻ .001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower ( p Ͻ .001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days. CONCLUSIONS:The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents

“…This finding stands in stark contrast to a plethora of prior data showing disparity in advance care planning and end-of-life care across ethnicities. [15][16][17] These findings show that a broad, rather complex public health intervention can be disseminated widely and effectively in a relatively brief period of time across a large, racially diverse state.…”

“…This finding stands in stark contrast to a plethora of prior data showing disparity in advance care planning and end-of-life care across ethnicities. [15][16][17] These findings show that a broad, rather complex public health intervention can be disseminated widely and effectively in a relatively brief period of time across a large, racially diverse state.The California POLST dissemination was a broad-based statewide effort that included a coordinated effort among stakeholders throughout the state, a coordinating organization supported with funding from a grant-making organization focused on healthcare, combined with a grassroots initiative. California state law (Assembly Bill 3000) in 2008 authorized the use of POLST throughout the state, effective January 1, 2009.…”

“…Cognitive status was measured using the validated MDS 3.0 Brief Interview for Mental Status (BIMS), 8 which was present for 69 % of residents, supplemented when missing with the staff assessment for 26 % or an indication that the resident was comatose (0.4 %). Using this combined variable, cognitive impairment was defined as none (BIMS score [13][14][15] or not impaired by staff assessment), mild to moderate (BIMS score 8-12), or severe (BIMS score 0-7 or impaired by staff assessment or comatose). To define functional status, we used the validated MDS Activities of Daily Living (ADL) scale, which ranges from 0 (independent in all seven ADLs) to 28 (total dependence in all seven ADLs).…”

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

“…9 Among patient characteristics, previous studies showed that being older, White, and having more medical comorbidities increases the likelihood of having a DNR order across multiple medical conditions. [7][8][9] Using a nationally representative sample of nearly 14,000 Medicare patients, Wenger and colleagues showed that the frequency and the factors that influence DNR use also varied significantly by medical diagnoses. 8 In that study, the rates of DNR use ranged from 4 % in patients admitted with hip fracture to 21 % in those admitted with a cerebrovascular accident.…”

“…[6][7][8][9] Because administrative data typically captures only those DNR orders placed in the first 24 h of hospitalization, most studies have only examined factors that are associated with early DNR orders. However, the factors that influence the likelihood of a DNR order later in the hospital course may be different.…”