Sex Differences in “Do Not Attempt Resuscitation” Orders After Out-of-Hospital Cardiac Arrest and the Relationship to Critical Hospital Interventions

Abstract

Purpose: Women who experience out-of-hospital cardiac arrest have similar rates of survival to hospital admission as men; however, women are less likely to survive to hospital discharge. We hypothesized that women would have higher rates of "do not attempt resuscitation" (DNAR) orders and that this order would be associated with lower use of aggressive interventions.Methods: We identified adult hospital admissions with a diagnosis of cardiac arrest (ICD-9 427.5) from the 2010 California State Inpatient Dataset. Multivariable logistic regression was used to test the association between patient sex and a DNAR order within the first 24 h of admission, adjusting for patient demographic characteristics and comorbid medical conditions. In secondary analysis, procedures performed after establishment of DNAR order and survival to hospital discharge were compared by sex.Findings: We analyzed 6562 patients (44% women, 56% men) who experienced out-of-hospital cardiac arrest and survived to hospital admission. In unadjusted analysis, more women than men had establishment of a DNAR order during the first 24 h of admission (23.4% versus 19.3%; P < 0.01). After adjusting for age, race, and comorbid conditions, women remained significantly more likely to have a DNAR order established during the first 24 h of their hospital admission after cardiac arrest compared with men (odds ratio ¼ 1.23; 95% CI, 1.09e1.40). No sex difference was found in procedures used after DNAR order was established.Implications: Female survivors of cardiac arrest are significantly more likely than men to have a DNAR order established within the first 24 h of in-hospital treatment. The establishment of a DNAR order is associated with patients undergoing fewer procedures than individuals who do not have a DNAR order established. Given that patients who have a DNAR order receive less-aggressive intervention after arrest, it is possible that an early DNAR order may contribute to sex differences in survival to hospital discharge.

Sex differences in survival after out-of-hospital cardiac arrest: a meta-analysis

“…Combined with factors, such as education level, religious belief, and economic level, females are more likely to issue the instruction of "Do not attempt resuscitation" at the early stage of OHCA, thus adopting more conservative treatment [ 12 ]. Overall, this leads to a poor prognosis of OHCA in females.…”

“…However, it is not clear whether sex differences in heart-related diseases affect the prognosis of OHCA. Multiple studies have addressed possible sex differences associated with OHCA prognosis, but the findings are inconsistent: some studies report no difference between males and females in survival after OHCA [ 7 , 11 ]; others have reported better survival for males or better survival for females [ 12 , 13 ]. A meta-analysis published in 2015 showed that the discharge survival rate of female OHCA patients was 10% higher than that of male, but the results of the latest large clinical studies show conflicting trends [ 14 ].…”

Sex difference on neurological outcomes and post-cardiac arrest care in out-of-hospital cardiac arrest patients treated with targeted temperature management

“…Third, currently, little information is available regarding the rates of WLST and limiting LST in men and women. Some previous studies, which identi ed that women were less likely to survive to hospital discharge after OHCA, postulated that this was due to increased WLST [30,31]. However, no study has included the results of prognostic tests to analyze the impact of sex on end-of-life decisions.…”

Sex-related disparities in the in-hospital management of patients with out-of-hospital cardiac arrest

“…37 Moreover, in previous stud-346 ies, more women than men had established a do-not-resuscitate 347 order. 38,39 The differences in resuscitation efforts by physicians 348 depending on patient sex might contribute to shorter CPR duration.…”