Alignment of Do-Not-Resuscitate Status With Patients’ Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest

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.

Implications of a recurrent in-hospital cardiac arrest on survival and neurological outcomes

“…Indeed, a prior study found that DNAR orders among patients with IHCA who achieved ROSC were not always aligned with patients’ prognoses. 3 Our study extends those initial findings and suggests that efforts to better communicate prognoses after IHCA with patients and their families may be needed.…”

“…Rates of DNAR were examined after successful resuscitation from the second cardiac arrest for patients with recurrent IHCA or recurrent OHCA and after the index cardiac arrest for patients with no recurrent IHCA, since this latter group of patients would not have had a second cardiac arrest. Since many patients who eventually die have DNAR orders closer to the time of death, and as we were interested in examining whether DNAR decisions correlated with an index or recurrent cardiac arrest, we defined DNAR status as a patient for whom a DNAR order was placed within 24 hours after ROSC, based on our prior work, 3 but also examined rates of DNAR at any time after ROSC in the 3 patient groups. Furthermore, we compared rates of withdrawal of care (i.e., “comfort care”) among patients with no recurrent IHCA, recurrent IHCA, and recurrent OHCA who achieved ROSC…”

“…Additionally, if patients with recurrent IHCA have worse survival outcomes, patterns of decision-making regarding Do Not Attempt Resuscitation (DNAR) orders and withdrawal of care between those with and without a recurrent IHCA are important to understand, as end-of-life decisions in patients with IHCA have not always been aligned with patients’ prognoses. 3 …”

Relationship Between the Duration of Cardiopulmonary Resuscitation and Favorable Neurological Outcomes After Out‐of‐Hospital Cardiac Arrest: A Prospective, Nationwide, Population‐Based Cohort Study

“…This may be particularly useful in areas where no termination‐of‐resuscitation rules are applied at the scene, as in Japan. However, the clinician in charge must recognize that do‐not‐resuscitate orders may not match the postcardiac arrest prognosis . For example, Fendler et al demonstrated that only 36% of patients with the worst prognosis obtained do‐not‐resuscitate orders after ROSC from an in‐hospital cardiac arrest.…”

“…However, the clinician in charge must recognize that do‐not‐resuscitate orders may not match the postcardiac arrest prognosis . For example, Fendler et al demonstrated that only 36% of patients with the worst prognosis obtained do‐not‐resuscitate orders after ROSC from an in‐hospital cardiac arrest. Therefore, a more accurate prognostication tool as well as adequate communication with family members to help them understand the prognosis is needed to facilitate shared, informed decision‐making.…”