The epidemiology of do-not-resuscitate orders in patients with trauma: a community level one trauma center observational experience

Abstract

BackgroundDo-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients.MethodsWe included all adults with trauma to a community Level I Trauma Center over 6 years (2008–2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications).ResultsIncluded were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3–8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay.ConclusionsOur analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-015-0094-2) contains supplementary material, which is available to authorized users.

Use and Outcomes of Noninvasive Ventilation for Acute Respiratory Failure in Different Age Groups

“…Stefan et al 2 also reported increasing use of NIV with age for 1,364,624 medical subjects hospitalized with an ARF diagnosis (12,21,28, and 34% in subjects age 18 -44, 45-64, 65-84, and Ն85 y old, respectively). The lower rates of NIV use compared with our study could be due to their reliance on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) coding 16 ; differences in prevalence of etiologies of ARF (pneumonia being the most common diagnosis); or different practices between our hospitals and those in the sample of Stefan et al 2 In addition, they observed that older subjects received less invasive mechanical ventilation and less expensive care overall, consistent with earlier studies 3,17,18 and with the idea that intensity of care decreases with aging as more patients and their proxies choose to limit treatment. In a 2-y prospective cohort study on subjects with ARF admitted to a medical ICU, Schortgen et al 6 also reported NIV use in 60% of elderly subjects (Ն80 y old) requiring ventilator support compared with only 32% of younger subjects.…”

“…Older patients (Ͼ85 y) more often received NIV than younger ones (12.7% vs 7%), 2 and were also more apt to have do-notintubate orders than younger ones. 3 Considering that NIV is frequently offered for management of ARF in patients with do-not-intubate orders as a ceiling of ventilator care or palliative therapy, [4][5][6][7][8][9] this also would be expected to favor greater use of NIV in the elderly.…”

“…Most prior studies on NIV use in the elderly have been retrospective or based on questionnaires or databases collected on the basis of billing codes, 2,3,[10][11][12][13] limiting the ability to identify clinical characteristics associated with NIV use. Additionally, current data regarding NIV use in the elderly has been derived mainly from hypercapnic subjects treated in ICUs or intermediate care units, 4,6,7 whereas elderly and do-not-intubate patients are not uncommonly treated on regular medical wards.…”

Organ Dysfunctions among Deaths in Critically Ill Patients

“…16 This study also showed that the mean ICU stay was 1.3 days, which is slightly less than that found in a Scottish ICU study among 873 patients (2.3days). 16 This could be explained by the lack of adequate and well-equipped ICU facilities and universal gold standard ICU protocols in most of the hospitals. Other reason could be due to the fact that most of the patients in our study were referred from other hospitals.…”

Predictors and outcome of invasive mechanical ventilation in hospitalized patients with sepsis: data from National Inpatient Sample

“…Prior studies suggest that physicians do not readily refer and admit older individuals >80 years to ICU despite a clear indication of the need to do so, and those admitted to the ICU often receive lesser intensive treatment (IMV and renal support), compared to patients <80 years, even after adjusting for illness severity [17,18]. Also, old age being a significant factor influencing the issue of ‘Do not resuscitate or intubate’ order, may result in decreased intensive management, partly explaining for the reduced use of IMV in critically ill elderly patients [19,20]. …”