Association of medical futility with do-not-resuscitate (DNR) code status in hospitalised patients

Abstract

Guidelines recommend a ‘do-not-resuscitate’ (DNR) code status for inpatients in which cardiopulmonary resuscitation (CPR) attempts are considered futile because of low probability of survival with good neurological outcome. We retrospectively assessed the prevalence of DNR code status and its association with presumed CPR futility defined by the Good Outcome Following Attempted Resuscitation score and the Clinical Frailty Scale in patients hospitalised in the Divisions of Internal Medicine and Traumatology/Orthopedics at the University Hospital of Basel between September 2018 and June 2019. The definition of presumed CPR futility was met in 467 (16.2%) of 2889 patients. 866 (30.0%) patients had a DNR code status. In a regression model adjusted for age, gender, main diagnosis, nationality, language and religion, presumed CPR futility was associated with a higher likelihood of a DNR code status (37.3% vs 7.1%, adjusted OR 2.99, 95% CI 2.31 to 3.88, p<0.001). In the subgroup of patients with presumed futile CPR, 144 of 467 (30.8%) had a full code status, which was independently associated with younger age, male gender, non-Christian religion and non-Swiss citizenship. We found a significant proportion of hospitalised patients to have a full code status despite the fact that CPR had to be considered futile according to an established definition. Whether these decisions were based on patient preferences or whether there was a lack of patient involvement in decision-making needs further investigation.

Medical futility regarding cardiopulmonary resuscitation in in-hospital cardiac arrests of adult patients: A systematic review and Meta-analysis

“…Half of the studies included hospitalized patients receiving CPR after IHCA 1,4,24,33,34,[26][27][28][41][42][43][46][47][48][49] and in three studies the study population consisted of hospitalized patients without IHCA. 25,30,40,52 Yet, some studies included more specific patient populations such as elderly patients, 35,44 oncological patients, 36,38 critically ill patients, 39 severe burn patients, 32 or patients with multiple IHCA. 29 One study only included patients with established DNR orders.…”

“…These varied broadly in content and specificity, and rarely consisted of more than one or two sentences. Six studies defined futility as a very low likelihood of survival after CPR following cardiac arrest 1,10,33,39,45,52 with one of them specifying a "1% chance of surviving 2 months after CPR". 39 Nine studies evaluating clinical risk scores solely presented a cut-off score indicating futility 24,42,44,52 or extremely low chance of survival with favorable neurologic outcome, defined as Cerebral Performance Category 1 10,47,48 or 1 to 2.…”

“…Six studies defined futility as a very low likelihood of survival after CPR following cardiac arrest 1,10,33,39,45,52 with one of them specifying a "1% chance of surviving 2 months after CPR". 39 Nine studies evaluating clinical risk scores solely presented a cut-off score indicating futility 24,42,44,52 or extremely low chance of survival with favorable neurologic outcome, defined as Cerebral Performance Category 1 10,47,48 or 1 to 2. 28,49 Ten studies provided unspecific definitions, defining futility either based on clinical conditions, e.g., age, metastatic cancer, or "acute or chronic impairments in almost any organ system in elderly patients" or based on an outcome, e.g., "prolonging the patient's suffering and therefore harming the patient".…”

“…29,32,34,37 DNR code status in patients for whom CPR was deemed futile Four studies reported how many patients for whom CPR was deemed futile had a DNR code status. 39,40,44,52 The definitions of futility among these studies and the rates of DNR code status varied considerably. In the study of Aarons et al 40 junior doctors gave a statement concerning the appropriateness of resuscitation in case of IHCA for each included patient.…”

“…Of these patients where CPR was considered to be futile, 44% (n = 17) had a DNR code status. Becker et al 52 assessed 2889 patients hospitalized at the Division of Traumatology/Orthopedics or Internal Medicine. Futility regarding CPR was defined as a Good Outcome Following Attempted Resuscitation (GO-FAR) score !…”