Do-not-resuscitate orders in patients with community-acquired pneumonia: a retrospective study

Abstract

Background: To investigate the use of do-not-resuscitate (DNR) orders in patients hospitalized with communityacquired pneumonia (CAP) and the association with mortality. Methods: We assembled a cohort of 1317 adults hospitalized with radiographically confirmed CAP in three Danish hospitals. Patients were grouped into no DNR order, early DNR order (≤48 h after admission), and late DNR order (> 48 h after admission). We tested for associations between a DNR order and mortality using a cox proportional hazard model adjusted for patient and disease related factors. Results: Among 1317 patients 177 (13%) patients received a DNR order: 107 (8%) early and 70 (5%) late, during admission. Patients with a DNR order were older (82 years vs. 70 years, p < 0.001), more frequently nursing home residents (41% vs. 6%, p < 0.001) and had more comorbidities (one or more comorbidities: 73% vs. 59%, p < 0.001). The 30-day mortality was 62% and 4% in patients with and without a DNR order, respectively. DNR orders were associated with increased risk of 30-day mortality after adjustment for age, nursing home residency and comorbidities. The association was modified by the CURB-65 score Hazard ratio (HR) 39.3 (95% CI 13.9-110.6), HR 24.0 (95% CI 11.9-48,3) and HR 9.4 (95% CI: 4.7-18.6) for CURB-65 score 0-1, 2 and 3-5, respectively. Conclusion: In this representative Danish cohort, 13% of patients hospitalized with CAP received a DNR order. DNR orders were associated with higher mortality after adjustment for clinical risk factors. Thus, we encourage researcher to take DNR orders into account as potential confounder when reporting CAP associated mortality.

Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders

“…Patients with EDNR had lower 7-, 30-, and 90-day survival; our finding is compatible with another study where EDNR was found to be an independent predictor for 28-day mortality [7]. In a Danish cohort of patients with community acquired pneumonia (CAP), EDNR was associated with higher mortality after adjustment for clinical risk factors [16]. Among intracerebral hemorrhage (ICH) patients, EDNR is an independent predictor of poor outcome [30,31]; 2.6 times more likely to die than those without DNR order [30].…”

“…Similarly, a Danish cohort of patients with community-acquired pneumonia (CAP) found patients with EDNR were older and more frequently nursing home residents (41% vs. 6%, p < 0.001). [16] Marrie et al, found that coming from a chronic care facility or a nursing home was a major demographic associated with DNR upon admission, and more than half (53.8%) from institutions had a DNR order in place on admission [17]. This may reflect nursing home policies or a greater awareness among this group to have advanced directives.…”

Do Not Attempt Resuscitation (DNAR) status in people with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study

“…Our findings suggest a higher rate of DNAR use (31%) than identified in previous studies of similar conditions. Studies of patients admitted with community-acquired pneumonia reported rates of DNAR use ranging from 13% to 29%, [6-10] while studies in severe sepsis or septic shock reported rates ranging from 9% to 20%. [11-14] DNAR decisions in these studies were associated with older age, but conflicting findings were reported around the use of invasive procedures.…”

“…Previous studies have estimated the prevalence of DNAR orders in patients admitted to hospital with community-acquired pneumonia [6-10] and sepsis,[11-14] and have attempted to identify factors associated with DNAR use, but we currently know very little about how DNAR orders have been used in people admitted with suspected COVID-19. The Pandemic Respiratory Infection Emergency System Triage (PRIEST) study was established to develop and evaluate triage tools for people presenting to hospital emergency departments with suspected COVID-19.…”

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study

“…Previous studies have estimated the prevalence of DNACPR decision in patients admitted to hospital with community-acquired pneumonia 6 , 7 , 8 , 9 , 10 and sepsis, 11 , 12 , 13 , 14 and have attempted to identify factors associated with DNACPR use, but we currently know very little about how DNACPR decision have been used in people admitted with suspected COVID-19. The Pandemic Respiratory Infection Emergency System Triage (PRIEST) study was established to develop and evaluate triage tools for people presenting to hospital emergency departments with suspected COVID-19.…”