Do-not-resuscitate orders for critically ill patients in intensive care

Abstract

End-of-life decision making frequently occurs in the intensive care unit (ICU). There is a lack of information on how a do-not-resuscitate (DNR) order affects treatments received by critically ill patients in ICUs. The objectives of this study were: (1) to compare the use of life support therapies between patients with a DNR order and those without; (2) to examine life support therapies prior to and after the issuance of a DNR order; and (3) to determine the clinical factors that influence the initiation of a DNR order in ICUs in Taiwan. A prospective, descriptive, and correlational study was conducted. A total of 202 patients comprising 133 (65.8%) who had a DNR order, and 69 (34.1%) who did not, participated in this study. In the last 48 hours of their lives, patients who had a DNR order were less likely to receive life support therapies than those who did not have a DNR order. Older age, being unmarried, the presence of an adult child as a surrogate decision maker, a perceived inability to survive ultimate discharge from the ICU, and longer hospitalization in the ICU were significant predictors of issuing a DNR order for critically ill patients. This study will draw attention to how, when, and by whom, critically ill patients' preferences about DNR are elicited and honored.

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]. …”

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

“…83,93 Although patient autonomy played an important role, 72,75,89 particularly among nurses, 73 one study 64 found that it did not significantly change the physician's decision. However, the presence of family, particularly adult children as surrogate decision-makers, 72,84,85 often aided decision-making.…”

“…The timings were described as days to death or days from admission, so it was difficult to identify commonalities of the timings of decision-making. DNACPR order decision-making ranged from admission or within 24 hours of admission 15,74,75,84,88,94 to less than 7 days before death. 79,84,85 Sometimes there were less than 24 hours before death, 84,85 with many emergency teams having to decide moments before death whether or not there was a DNACPR order already in place.…”

“…69,70,78 Twelve articles included reviews or audits of medical records, registry of deaths or MET calls, 16,75,[79][80][81][82][83][84][85][86][87][88] of which two were of high quality 16,86 two were of medium quality 85,87 and eight were of low quality. 75,[79][80][81][82][83][84]88 Eight articles included qualitative designs of interviews, focus groups and observations; 14,15,40,67,[89][90][91][92] of these, three were deemed high quality, 15,89,92 three were deemed medium quality 14,40,91 and two were deemed low quality. 67,90 Records after duplicates removed (n = 3098)…”

“…38,[63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78] Of these 17 articles, 12 were deemed low-quality studies, [63][64][65][66][67][68][72][73][74][75][76][77] two were deemed medium quality 38,71 and three were deemed high quality. 69,70,78 Twelve articles included reviews or audits of medical records, registry of deaths or MET calls, 16,75,[79][80][81][82][83][84][85][86][87][88] of which two were of high quality 16,86 two were of medium quality 85,…”