Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates

Abstract

Background The impact of do not resuscitate (DNR) orders have not been systematically evaluated in acute trauma research. We determined the frequency, timing and impact on mortality-based effect estimates for patients with DNR orders in the the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Methods Trauma patients surviving at least 30 minutes and transfused ≥1 RBC unit within 6 hours of admission (n=1245) from ten Level 1 centers were enrolled. We report descriptive statistics and results from survival analysis to compare the association of blood product transfusion ratios with outcome defined as mortality and as a composite, DNR and death. Results DNRs were reported for 95 patients (7.6%) with 94 in-hospital deaths. There were 172 deaths without DNRs. Of 90 known DNR order times, the median was 53 hours (IQR=9-186 hours) after admission; the median DNR-to-death time was 10 (2-32) hours. DNRs were for comfort measures only (43%), no CPR (40%), and no intubation or CPR (16%). Compared with the 116 non-DNR deaths that occurred after the earliest DNR order (2-hours), the DNR decedents were significantly older with a less severe base deficit, fewer RBC and plasma transfusions, and a later median time of death: 98 (21-230) vs. 17 (4-91) hours. In multivariable Cox models that accounted for time-varying blood product ratios, the associations were consistent regardless of whether outcome was defined as mortality or the composite. Conclusion DNR orders were instituted after the 24-hour period of highest mortality risk and more often in older patients not in severe shock. Findings from the primary PROMMTT analyses of the impact of blood product ratios on survival did not materially change when the original mortality outcome was redefined as a composite of DNR or death. DNR orders are potentially an important mediating variable that should be systematically evaluated in trauma research.

Variability in Early Do Not Attempt Resuscitation Orders Among Patients With Serious Traumatic Brain Injury

“…DNAR orders have been shown to affect mortality comparisons among patients with hemorrhagic shock. 14 Further study is needed to determine the appropriate timing for prognosticating outcomes following TBI, as the first 24 hours have been shown to be too early to accurately determine neurologic outcome following cardiac arrest. 13 Our findings also provide an opportunity for subsequent studies to improve on the limitations of the current study by accounting for detailed patient-level confounders, clustering at the provider level, patient/family preferences, and investigating more detailed contextual information regarding the decision-making involved with placing DNAR orders on TBI patients.…”

Coagulopathy After Severe Pediatric Trauma

“…Other published studies have not shown any improvement in survival utilizing this approach [104-106]. In contrast, two recent studies have still shown a benefit of using a high FFP-blood ratio after adjusting for survival bias [107, 108]. Regardless of these results, a higher ratio transfusion approach has been adopted at the majority of level 1 adult trauma centers and prospective, randomized controlled trials are currently underway to determine optimal ratios for patients with severe hemorrhagic blood loss [109].…”

Preadmission Do Not Resuscitate advanced directive is associated with adverse outcomes following acute traumatic injury

“…This study has significant ramifications as both DNR status and withdrawal of care have important implications for outcome studies and hospital benchmarking [16,37]. Failure to adjust outcomes for DNR status may demonstrate inappropriately poor outcomes.…”

“…In multi-center studies evaluating trauma patients admitted to the ICU, the presence of a DNR order is associated with substantially higher inhospital mortality rates of 88% or 99% [14,15,16].…”