Abstract
Importance
After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.
Objective
To assess whether patients' decisions for Do-Not-Resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis.
Design, Setting, Participants
Within Get With The Guidelines®-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 U.S. hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (i.e., without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined.
Exposure
DNR orders within 12 hours of ROSC.
Main Outcome
Likelihood of favorable neurological survival.
Results
Overall, 5,944 (22.6% [95% CI: 22.1%, 23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P <0.05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI: 6.1%, 8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (62.8%, 66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (34.2%, 37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (3.3%, 4.7%) (P for both trends <0.001). This pattern was similar when DNR orders were re-defined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI: 29.9%, 31.1%]) compared with those with DNR orders (1.8% [95% CI: 1.6%, 2.0%]), and this pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis.
Conclusions and Relevance
Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including among those with the best prognosis.
Introduction
Do-Not-Resuscitate (DNR) orders are often established for patients whose prognosis is poor. One such example is in-hospital cardiac arrest, which affects nearly 200,000 patients in the U.S. annually, with rates of favorable neurological survival (i.e., survival without severe cognitive disability) of <20%.1 Accordingly, this poor prognosis frequently prompts discussions about DNR status among resuscitated patients and their families.2 However, the likelihood of favorable neurological survival is variably influenced by many factors, including patients' age, illness severity, comorbidities, and arrest characteristics.3-7 It therefore remains unknown if real-world decisions for DNR orders after successful resuscitation from in-hospital cardiac arrest are aligned with patients' likelihood of favorable neurological survival.
A critical challenge in making decisions about DNR status in this clinical setting has been the lack of a tool to quantify a patient's prognosis after initial resuscitation from an in-hospital cardiac arrest. Recently, such a prognosis tool was developed and internally validated.8 Accordingly, to better understand current practice patterns for DNR decisions for in-hospital cardiac arrest, we leveraged the multicenter Get With The Guidelines®-Resuscitation (GWTG-R) registry to examine whether DNR orders after successful resuscitation from an in-hospital cardiac arrest occurred primarily in patients with a low likelihood of favorable neurological survival. Moreover, we explored whether patients with DNR orders had similar or lower hospitalization costs and lengths of stay after ROSC compared with patients without DNR orders, even among those with a high likelihood of a good neurological outcome.
Methods
Study Design
The Institutional Review Board (IRB) of the Mid-America Heart Institute approved this study and waived the requirement for informed consent. GWTG-R is sponsored by the American Heart Association, which had no role in the study design, data analysis or manuscript preparation and revision.
GWTG-R registry is a multi-center, observational registry of in-hospital cardiac arrests among U.S. hospitals that was begun in 2000. Hospital participation in the registry is voluntary, and details of the registry have been previously described in detail.9 In short, trained research personnel at each participating hospital identify and enroll all patients with in-hospital cardiac arrest (defined as unresponsiveness, apnea, and absence of a palpable central pulse), without prior DNR orders, and who have undergone cardiopulmonary resuscitation (CPR). This is accomplished through multiple sources of case identification, including medical records, centralized cardiac-arrest flow sheets, hospital paging-system logs, code cart checks, pharmacy tracer drug records, and hospital billing charges for use of resuscitation medications.5, 9 Standardized data collection methods, including Utstein consensus definitions for all variables and outcomes, and strict oversight across all participating centers ensure accuracy, uniformity and completeness of the data.7, 10, 11 Outcome, A Quintiles Company, is the data collection coordination center for the American Heart Association/American Stroke Association Get With The Guidelines® programs.
Study Population
Information on DNR status after return of spontaneous circulation (ROSC) was introduced into the data collection form of GWTG-R in April of 2006. Thus, the cohort consisted of adult patients who were 18 years or older with an in-hospital cardiac arrest between April 2006 and September 2012. To focus on patients who arrested in either general inpatient or intensive care units, patients were excluded who experienced in-hospital cardiac arrest in the emergency department, operating room, procedural and post-procedural areas. For the purposes of this study, in which decisions about DNR status after ROSC were assessed, patients who died during the acute resuscitation, as well as patients from hospitals that did not routinely collect information on DNR status, were excluded. Additionally, patients were excluded if they had missing data on neurological status at discharge, as this variable comprised one of the study outcomes. Finally, patients for whom the time of DNR decision could not be calculated due to missing or implausible times were excluded.
Definition of Variables
This study examined the relationship between DNR orders after initial resuscitation from in-hospital cardiac arrest and a patient's likelihood of favorable neurological survival. Since many patients who eventually die have DNR orders closer to the time of death, and as this study examined whether DNR decisions was associated with prognosis, we defined DNR status—our independent variable—as a patient for whom a DNR order was placed within 12 hours after ROSC. Successfully resuscitated patients without DNR orders at any time during their admission or those with a DNR order placed more than 12 hours after ROSC were defined as patients without DNR status. In sensitivity analyses, DNR status was defined as within 24 hours, 72 hours, and 5 days after ROSC.
Favorable neurological survival was defined as survival to hospital discharge without severe neurological disability. Neurological disability in GWTG-R is measured by Cerebral Performance Category (CPC) scores, wherein a CPC of 1 to 5 denoted little to no neurological disability, moderate disability, severe disability, coma or vegetative state, and brain death, respectively. Based on prior work, favorable neurological survival was defined as survival to hospital discharge with a CPC score of 1 or 2.8,12 Our dependent variable, likelihood of favorable neurological survival, was defined by each individual patient's expected prognosis, which will be described further below.
Statistical Analysis
Because of the large study sample size, baseline differences between patients with and without DNR orders were compared using standardized differences, which accounts for the large sample size of the compared groups. Based on prior work, a standardized difference of greater than 10% was considered a significant and meaningful difference.13
To evaluate whether a patient's decision to be DNR was aligned with their prognosis, the discriminative accuracy of 4 prognosis risk scores for in-hospital cardiac arrest was first evaluated: 1) the Pre-Arrest Morbidity (PAM) score14, 2) the Prognosis After Resuscitation (PAR) score15, 3) the Cardiac Arrest Survival Post-Resuscitation In-hospital (CASPRI) score8, and 4) the Good Outcome Following Attempted Resuscitation (GO-FAR) score.16 To accomplish this, four separate multivariable hierarchical logistic regression models were constructed to predict favorable neurological survival using the variables for each prognostic score. Two-level hierarchical models were used to account for clustering of patients within hospitals, with individual hospitals modeled as random effects and patient characteristics as fixed effects within each hospital.17, 18 The c-statistics from each model were then compared to determine which model had the highest discriminative accuracy. As the CASPRI risk score had significantly higher discrimination than the three other prognosis scores (eTable 1), subsequent analyses evaluating DNR decision-making and prognosis primarily used the CASPRI risk score.
We then calculated each patient's likelihood of favorable neurological survival using the CASPRI score.8 Briefly, this score was derived and validated within GWTG-R using data from 42,957 patients. A final parsimonious model with excellent discrimination (c-statistic of 0.802) and calibration identified the following 11 significant predictors of favorable neurological survival among patients successfully resuscitated from an in-hospital cardiac arrest: age, initial cardiac arrest rhythm, pre-arrest neurological disability, hospital location of arrest, duration of cardiopulmonary resuscitation, requirement for mechanical ventilation at the time of cardiac arrest, and the presence of renal insufficiency, hepatic insufficiency, sepsis, malignant disease and hypotension at the time of cardiac arrest. The CASPRI score was calculated for each patient in our study cohort by applying the model coefficients to each patient's case-mix profile. CASPRI scores range from 0 to 50, with higher scores indicating a lower likelihood of favorable neurological survival. To assess the alignment of early decision-making for DNR status with patients' prognoses, the cohort was stratified into deciles of CASPRI score and rates of DNR orders, as well as actual favorable neurological survival, were examined within each CASPRI decile. As sensitivity analyses, the analyses were repeated after re-defining DNR orders as those made within 24 hours, 72 hours, and 5 days of ROSC. In addition, to examine whether DNR orders within the first 12 hours were surrogates for comfort care, the likelihood of an order for withdrawal of life sustaining treatments at any time after ROSC was examined for patients with and without DNR orders. Finally, as exploratory analyses, we examined length of hospital stay from time of ROSC for patients with and without DNR orders, stratified by CASPRI decile. For the 9733 patients who were 65 years of age or older and linked to Medicare inpatient claims files using a probabilistic matching algorithm from our prior work19, 20, index hospitalization costs for patients with and without DNR orders were also compared. Hospitalization costs were obtained from the inpatient Medicare files and represented actual reimbursement of the index hospitalization paid to hospitals for each patient linked to Medicare claims data.
For all analyses, the null hypothesis was evaluated at a two-side significance level of 0.05 with 95% confidence intervals (CIs). All analyses were conducted with SAS 9.1 (SAS Institute, Cary, NC) and R version 2.6.2.21
Results
Within GWTG-R, an initial 72,875 in-hospital cardiac arrest events from 459 hospitals were identified (Figure 1). Excluded were 13,286 patients with an in-hospital cardiac arrest in procedural or operative settings or the emergency room, 25,618 patients who died during the acute resuscitation, 1,810 patients whose hospitals did not routinely collect information on DNR status, 1,863 patients with missing data on neurological status at discharge, and 3,971 patients for whom the timing of DNR decisions could not be calculated. For the 8013 patients with missing data on DNR or discharge neurological status (last 3 exclusions), there were no significant differences in baseline characteristics when compared with those of the study cohort (eTable 2). The final cohort included 26,327 patients from 406 hospitals who were successfully resuscitated after in-hospital cardiac arrest.
Figure 1. Patient Cohort Exclusion Flow Chart.
Abbreviations: CPC, Cerebral Performance Category; DNR, do not resuscitate; ED, emergency department; OR, operating room; ROSC, return of spontaneous circulation
Overall, 5,944 (22.6% [95% CI: 22.1%, 23.1%]) had DNR orders within the first 12 hours after ROSC, while 20,383 (77.4% [95% CI: 76.9%, 77.9%]) did not. Table 1 compares characteristics of patients with and without DNR orders. Patients with DNR orders were older, more frequently of white race, and were more likely to have baseline neurological disability (CPC > 1). In addition, they had higher rates of pre-existing conditions including hypotension, respiratory insufficiency, renal insufficiency, hepatic insufficiency, metabolic or electrolyte abnormalities, and pneumonia. Finally, patients with DNR orders after ROSC were more likely to have cardiac arrest rhythms associated with lower overall survival (e.g., pulseless electrical activity) and longer resuscitation times.
Table 1. Baseline Characteristics of Study Participants.
| DNR (n = 5944) |
Non-DNR (n = 20,383) |
Standardized Differences (%) | |
|---|---|---|---|
| Demographics | |||
| Age, mean ± SD | 68.6 ± 15.2 | 64.2 ± 15.7 | 28.5 |
| Female, no. (%) | 2775 (46.7) | 8663 (42.5) | 8.5 |
| Race, no. (%) | |||
| White | 4310 (73.6) | 13,697 (68.3) | 11.8 |
| Black | 1165 (19.9) | 4726 (23.6) | 8.9 |
| Other | 381 (6.5) | 1644 (8.2) | 6.5 |
|
| |||
| Conditions present prior to admission, no. (%) | |||
| Heart failure | 1225 (20.6) | 4279 (21.0) | 1.0 |
| Myocardial infarction or ischemia | 851 (14.3) | 2974 (14.6) | 0.8 |
|
| |||
| Conditions present at time of cardiac arrest, no. (%) | |||
| Heart failure | 996 (16.8) | 3783 (18.6) | 4.7 |
| Myocardial infarction or ischemia | 809 (13.6) | 2814 (13.8) | 0.6 |
| Arrhythmia | 1867 (31.4) | 6447 (31.6) | 0.5 |
| Hypotension | 2065 (34.7) | 5003 (24.5) | 22.5 |
| Respiratory insufficiency | 2963 (49.8) | 8864 (43.5) | 12.8 |
| Renal insufficiency | 2499 (42.0) | 7501 (36.8) | 10.7 |
| Hepatic insufficiency | 661 (11.1) | 1622 (8.0) | 10.8 |
| Metabolic or electrolyte abnormality | 1264 (21.3) | 3096 (15.2) | 15.8 |
| Diabetes mellitus | 1807 (30.4) | 7040 (34.5) | 8.9 |
| Baseline depression in central nervous system function* | 820 (13.8) | 2159 (10.6) | 9.8 |
| Acute stroke | 275 (4.6) | 767 (3.8) | 4.3 |
| Acute central nervous system, non-stroke event | 455 (7.7) | 1354 (6.6) | 3.5 |
| Pneumonia | 983 (16.5) | 3112 (15.3) | 3.3 |
| Septicemia | 1447 (24.3) | 3779 (18.5) | 3.8 |
| Major trauma | 200 (3.4) | 832 (4.1) | 3.7 |
| Metastatic or hematologic malignancy | 1014 (17.1) | 2250 (11.0) | 4.7 |
|
| |||
| Interventions in place at time of cardiac arrest, no. (%) | |||
| Mechanical ventilation | 2428 (40.8) | 6365 (31.2) | 20.1 |
| Pacemaker | 334 (5.6) | 1321 (6.5) | 18.6 |
| Dialysis | 254 (4.4) | 789 (4.0) | 6.4 |
|
| |||
| Event characteristics, no. (%) | |||
| Night | 2197 (37.1) | 6543 (32.4) | 10.0 |
| Weekend | 1776 (29.9) | 5824 (28.6) | 2.9 |
| Location, no. (%) | |||
| Intensive care unit | 3896 (65.5) | 11,985 (58.8) | 13.9 |
| Monitored unit | 1273 (21.4) | 5706 (28.0) | 15.3 |
| Non-monitored unit | 775 (13.0) | 2692 (13.2) | 0.5 |
| Initial cardiac rhythm, no. (%) | |||
| Asystole | 2028 (34.1) | 6888 (33.8) | 0.7 |
| Pulseless electrical activity | 3457 (58.2) | 10,781 (52.9) | 10.6 |
| Ventricular fibrillation | 423 (7.1) | 2539 (12.5) | 18.0 |
| Ventricular tachycardia | 36 (0.6) | 175 (0.9) | 3.0 |
| Time to ROSC (minutes), | |||
| mean ± SD | 16.4±15.2 | 14.5±16.1 | 12.5 |
| median (IQR) | 12 (6, 21) | 10 (5,19) | 12.5 |
|
| |||
| Cerebral Performance Category (CPC)§ on admission, no. (%) | |||
| CPC 1 | 2436 (50.7) | 9802 (58.8) | 16.4 |
| CPC 2 | 1244 (25.9) | 4006 (24.0) | 4.3 |
| CPC 3 | 691 (14.4) | 1895 (11.4) | 9.0 |
| CPC 4 | 435 (9.0) | 956 (5.7) | 12.7 |
| CPC 5 | 1 (<1.0) | 5 (<1.0) | 0.6 |
Defined as a motor, cognitive, or functional deficit on admission
The Cerebral Performance Category (CPC) score is a validated measure of neurological disability ranging from 1 to 5 with the following definitions: 1 – no or mild neurological disability, 2 - moderate disability, 3 - severe disability, 4 - persistent coma or vegetative state, or 5 – brain death.
Abbreviations: DNR, Do Not Resuscitate; IQR, interquartile range; ROSC, return of spontaneous circulation; SD, standard deviation
Relationship Between DNR Status and Expected Prognosis
The rate of favorable neurological survival was 24.0% (95% CI: 23.5%, 24.5%) among patients with ROSC. When patients were stratified by prognosis deciles, this rate was 64.7% in decile 1 and decreased to 4.0% in decile 10 (P for trend <0.001) (Table 2). The proportion of patients with DNR orders increased as prognosis worsened (i.e., higher deciles), from 7.1% in decile 1 to 36.0% in decile 10 (P for trend <0.001). Of all patients in decile 10, 64.0% (95% CI: 62.2%, 65.8%) did not have DNR orders after ROSC despite the decile's 4% (95% CI: 3.3%, 4.7%) rate for favorable neurological survival. Compared with patients in decile 1, patients in decile 10 were much older; had higher rates of comorbidities; and had markedly longer mean resuscitation times (20.3 vs. 5.7 minutes) (eTable 3). Moreover, the majority of patients in decile 10 (78.1% [95% CI: 76.5%, 79.7%]) had severe neurological disability or worse prior to their cardiac arrest (with 25.7% [95% CI: 24.0%, 27.4%] in a comatose state) compared with only 0.3% (95% CI: 0.01%, 0.21%) in decile 1.
Table 2. Rates of Favorable Neurological Survival* and DNR within 12 Hours after ROSC by Prognosis Score Decile.
| CASPRI Score§ Decile | Median (Range) CASPRI score per Decile | No. Of Patients | Overall Survival Rate* no. (%) |
Proportion with DNR Orders no. (%) |
Survival Rate* Among Patients with DNR Orders no. (%) |
Survival Rate* Among Patients without DNR Orders no. (%) |
|---|---|---|---|---|---|---|
|
| ||||||
| Overall | 22 (0,44) | 26327 | 6318 (24.0) | 5944 (22.6) | 105 (1.8) | 6213 (30.5) |
|
| ||||||
| 1 | 8 (0,10) | 2396 | 1550 (64.7) | 169 (7.1) | 12 (7.1) | 1538 (69.1) |
| 2 | 12 (11,12) | 1726 | 834 (48.3) | 181 (10.5) | 11 (6.1) | 823 (53.3) |
| 3 | 14 (13,14) | 2535 | 892 (35.2) | 372 (14.7) | 18 (4.9) | 874 (40.4) |
| 4 | 16 (15,16) | 3359 | 937 (27.9) | 601 (17.9) | 11 (1.8) | 926 (33.6) |
| 5 | 17 (17, 17) | 1857 | 389 (20.1) | 398 (21.4) | 9 (2.3) | 380 (26.1) |
| 6 | 18 (18,19) | 3696 | 679 (18.4) | 890 (24.1) | 23 (2.6) | 656 (23.4) |
| 7 | 20 (20, 20) | 1680 | 262 (15.6) | 465 (27.7) | 4 (0.9) | 258 (21.2) |
| 8 | 21 (21,22) | 2840 | 347 (12.2) | 749 (26.4) | 4 (0.5) | 343 (16.4) |
| 9 | 24 (23,26) | 3571 | 320 (9.0) | 1160 (32.5) | 13 (1.1) | 307 (12.7) |
| 10 | 29 (27,44) | 2667 | 108 (4.0) | 959 (36.0) | 0 (0.0) | 108 (6.3) |
CASPRI is a validated score for prognosis after ROSC. Scores range from 0 to 50, and higher scores represent a worse prognosis.
Refers to survival with a Cerebral Performance Score of CPC 1 or 2
Abbreviations: CASPRI, Cardiac Arrest Survival Post-Resuscitation In-hospital; DNR, Do Not Resuscitate; ROSC, return of spontaneous circulation
In sensitivity analyses, there were only an additional 1165 (4.4% [95% CI: 4.2%, 4.6%]), 1779 (6.8% [95% CI: 6.5%, 7.1%]), and 877 (3.3% [95% CI: 3.1%, 3.5%]) patients with DNR orders between >12 and 24 hours, >24 hours and 3 days, and >3 and 5 days, respectively, after ROSC, with no significant change in patterns of DNR decisions by patients' prognosis (Figure 2). Finally, there was a similar pattern of low DNR rates in the highest risk deciles when the analyses were repeated using the PAM, PAR, and GO-FAR prognosis scores (eFigure 1).
Figure 2. Rates of DNR up to 5 Days After Cardiac Arrest, Stratified by CASPRI Score Decile.
Abbreviations: DNR, do not resuscitate; CASPRI, Cardiac Arrest Survival Post-Resuscitation In-hospital
Relationship Between DNR Status and Actual Outcomes
Among patients with DNR orders after ROSC, 105 (1.8% [95% CI: 1.6%, 2.0%]) had favorable neurological survival. Rates for this outcome remained relatively low regardless of CASPRI score decile, including those with a high predicted likelihood of favorable neurological survival (e.g., 7.1% [95% CI: 6.1%, 8.1%] for patients with DNR orders in decile 1) (Table 2). In contrast, 6,213 (30.5% [95% CI: 29.9%, 31.1%])) of the 20,383 patients without DNR orders had favorable neurological survival, with substantially higher rates in the lower CASPRI deciles (e.g., 69.1% [95% CI: 67.3%, 70.9%] in decile 1 vs. 6.3% [95% CI: 5.4%, 7.2%] in decile 10).
DNR orders were not surrogates for withdrawal of life-sustaining treatments, as only 47.5% (95% CI: 46.9%, 48.1%) of patients with DNR orders within 12 hours of ROSC withdrew life-sustaining treatments at any time after ROSC (eTable 4). Nonetheless, patients with DNR orders had shorter lengths of stay after ROSC and lower hospitalization costs than patients without DNR orders, regardless of prognosis risk (Table 3). There were no major differences in baseline neurological status, resuscitation duration, location of arrest, and most comorbidities between patients with and without DNR orders in deciles 1 and 10 to account for these large differences in resource use (eTable 5). Notably, hospitalization costs for patients with DNR orders in decile 1 were similar to those of decile 10 although only 0.4% (95% CI: 0.1%, 0.6%) of patients with DNR orders in decile 1 had severe neurological disability or worse, as compared with 79.2% (95% CI: 77.7%, 80.7%) in decile 10 (see Table 3).
Table 3. Resource Use by Patients With and Without DNR orders.
Length of stay after ROSC (A) and total hospitalization costs (B) for patients with and without DNR orders are compared within each prognosis risk decile.
| (A) Length of Stay after ROSC (LOS) | |||||
|---|---|---|---|---|---|
| CASPRI§ | Patients without DNR Orders | Patients with DNR Orders | |||
| Decile | n | LOS, days, median (IQR) | n | LOS, days, median (IQR) | P value |
|
| |||||
| 1 | 2227 | 10 (4, 19) | 169 | 0 (0, 1) | <.0001 |
| 2 | 1545 | 9 (2, 21) | 181 | 0 (0, 1) | <.0001 |
| 3 | 2163 | 8 (1, 21) | 372 | 0 (0, 1) | <.0001 |
| 4 | 2758 | 6 (1, 18) | 601 | 0 (0, 1) | <.0001 |
| 5 | 1459 | 5 (1, 16) | 398 | 0 (0, 1) | <.0001 |
| 6 | 2806 | 5 (1, 6) | 890 | 0 (0, 1) | <.0001 |
| 7 | 1215 | 4 (1, 15) | 465 | 0 (0, 0) | <.0001 |
| 8 | 2091 | 3 (1, 15) | 749 | 0 (0, 0) | <.0001 |
| 9 | 2411 | 3 (1, 13) | 1160 | 0 (0, 0) | <.0001 |
| 10 | 1708 | 2 (0, 10) | 959 | 0 (0, 0) | <.0001 |
| (B) Total Hospitalization Costs* | |||||
|---|---|---|---|---|---|
| CASPRI§ | Patients without DNR Orders | Patients with DNR Orders | |||
| Decile | n | Costs, US $, mean ± SD | n | Costs, US $, mean ± SD | P value |
|
| |||||
| 1 | 629 | $42,618 ± $1579 | 63 | $21,522 ± $4990 | <.0001 |
| 2 | 474 | $47,218 ± $1819 | 75 | $18,823 ± $4574 | <.0001 |
| 3 | 695 | $40,376 ± $1502 | 144 | $18,557 ± $3301 | <.0001 |
| 4 | 937 | $40,553 ± $1294 | 233 | $19,052 ± $2601 | <.0001 |
| 5 | 551 | $36,993 ± $1687 | 166 | $17,970 ± $3074 | <.0001 |
| 6 | 1009 | $37,602 ± $1247 | 414 | $18,287 ± $1947 | <.0001 |
| 7 | 453 | $36,960 ± $1863 | 219 | $23,908 ± $2677 | <.0001 |
| 8 | 781 | $34,155 ± $1417 | 329 | $20,810 ± $2184 | <.0001 |
| 9 | 947 | $35,297 ± $1288 | 525 | $19,104 ± $1732 | <.0001 |
| 10 | 654 | $32,323 ± $1550 | 435 | $19,901 ± $1904 | <.0001 |
|
| |||||
| P for trend <0.001 | P for trend=0.56 | ||||
CASPRI is a validated score for prognosis after ROSC. Scores range from 0 to 50, and higher scores represent a worse prognosis.
Applies to the 9733 patients who were linked to Medicare inpatient files
Abbreviations: CASPRI, Cardiac Arrest Survival Post-Resuscitation In-hospital; DNR, Do Not Resuscitate; ROSC, return of spontaneous circulation; SD, standard deviation
Discussion
In this national registry of in-hospital cardiac arrest, we found that DNR orders after successful resuscitation were generally aligned with patients' likelihood for favorable neurological survival, with increasing rates of DNR as a patient's likelihood to survive without neurological disability decreased. Nonetheless, almost two-thirds of patients with the worst prognosis did not have DNR orders, even though only 4.0% of patients within this decile had favorable neurological survival. Moreover, patients who had DNR orders despite a good prognosis had significantly lower survival and less resource use than patients without DNR orders who had a similar prognosis after ROSC. Our findings suggest that, while DNR orders after resuscitation from in-hospital cardiac arrest are correlated with expected prognosis, there may be opportunities to better align DNR decisions with patients' prognosis.
Several studies have reported rates of DNR orders in patients hospitalized with other disease conditions, ranging from 9% in acute myocardial infarction,22 13-22% in acute stroke,23, 24 22% in community-acquired pneumonia,25 to 38-47% in initial survivors of out-of-hospital cardiac arrest.26, 27 While these prior studies reported overall rates of DNR, they did not assess whether code status decision-making was aligned with a patient's prognosis. To our knowledge, this is the first study to analyze the association between DNR decision-making and patients' expected prognosis to better understand contemporary practice patterns.
Among patients with a low likelihood of favorable neurological survival after in-hospital cardiac arrest, our findings highlight the potential to improve DNR decision-making. Since 78% of patients with the worst prognosis (decile 10) had severe neurological disability or were comatose prior to their cardiac arrest, and given long resuscitation times, it was notable that only 36% of patients in this decile had DNR orders after ROSC, and this rate remained below 50% even when DNR status was re-defined as any time within 5 days after ROSC. Patients' decisions to have DNR orders may be motivated by many factors, including inaccurate clinician prognostication, inadequate communication, poor understanding of the prognosis, family influence, or patients' personal beliefs and goals. Within GWTG-R, we were not able to distinguish between these possibilities. It is also the case that a DNR order is not the appropriate choice for all patients with a very poor prognosis, and some patients opt for aggressive treatment regardless of prognosis. However, our findings suggest that DNR decision-making can be better aligned in patients with a low likelihood for favorable neurological survival, and future use of prognosis tools can facilitate shared, informed decision-making for DNR orders in this patient group.
It should also be noted that some patients with the best prognosis had DNR orders soon after ROSC. The survival rate of 7.1% among patients with DNR orders in decile 1, however, differed markedly from patients without DNR orders (69.1%) who had a similar prognosis score profile, and this pattern was repeated across all prognosis score deciles (see Table 2). Whether the survival difference by DNR status among patients with a high likelihood for favorable neurological survival reflects less aggressive care in patients with DNR orders or factors not measured in a prognosis tool remains unknown and is an area of future research. Nevertheless, patients who had DNR orders in the setting of a favorable prognosis (e.g., decile 1) did not differ substantially from patients without DNR orders. Of concern, total hospitalization costs for patients with DNR orders in decile 1 were similar to those for patients with DNR orders in decile 10 who had the worst prognosis (see Table 3), despite large differences in resuscitation duration and baseline neurological disability between these two populations (see eTable 5). Although we are unable to distinguish whether DNR orders were a marker or mediator for worse outcomes, these initial insights raise questions about whether DNR decisions may have led to lower intensity and aggressiveness of care for patients with DNR orders, especially for those with a good prognosis. In this setting, use of decision support tools may reduce the possibility of decreased treatment intensity in those with a high likelihood of favorable neurological survival.
Our study should be interpreted in the context of certain limitations. First, the CASPRI score has been internally validated but still requires external validation. Therefore, the clinical applicability of this tool for hospitals not participating within GWTG-R may be limited. Second, the occurrence, frequency and content of clinician-patient discussions about early DNR status were not measured in GWTG-R. Therefore, the reasons why some patients in the deciles with the best prognosis chose to be DNR while others with the worst prognosis did not could not be determined. Studies are needed to assess the extent to which this is due to patients' beliefs and preferences or discordance between physicians' perceptions of patients' prognoses and those of available prognosis tools. Third, although a prognosis tool with excellent discrimination was used, it is likely that some decisions regarding DNR status may reflect unmeasured patient characteristics that were not included in the prediction tool. This is an especially germane limitation in regard to those patients with good neurological prognosis who nevertheless had DNR orders after ROSC. Finally, despite a wealth of evidence that DNR status is associated with mortality in a number of clinical settings, it is not established whether patients' DNR status is a marker or mediator of survival. Delineation of the exact nature of this relationship merits further study.
Conclusions
Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including among those with the best prognosis.
Supplementary Material
Acknowledgments
Funding/Support:
Dr. Fendler is supported by a T32 grant from the NHLBI (T32HL110837).
Dr. Chan is funded by an R01 grant from the NHLBI (1R01HL123980).
Dr. Chen is supported by a K-award from AHRQ (K08 HS020671).
GWTG-Resuscitation is sponsored by the American Heart Association, which had no role in the study design, data analysis or manuscript preparation and revision.
Footnotes
Disclosures: None of the authors have any relevant conflicts of interest or disclosures.
Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Authorship: Drs. Fendler and Chan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Design and Conduct of the Study: Fendler, Chan
Collection, Management, Analysis, and Interpretation of the Data: Fendler, Spertus, Kennedy, Chen, Perman, Chan
Preparation, Review, or Approval of the Manuscript: Fendler, Spertus, Kennedy, Chen, Perman, Chan
Decision to Submit the Manuscript for Publication: Fendler, Chan
Contributor Information
Timothy J. Fendler, Email: fendlert@umkc.edu.
John A. Spertus, Email: spertusj@umkc.edu.
Kevin F. Kennedy, Email: kfkennedy@saint-lukes.org.
Lena M. Chen, Email: lenac@med.umich.edu.
Sarah M. Perman, Email: sarah.perman@ucdenver.edu.
Paul S. Chan, Email: paulchan.mahi@gmail.com.
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