Who Has Life-Sustaining Therapy Withdrawn After Injury?

Watch, Libby; Saxton-Daniels, Stephanie; Schermer, Carol R.

doi:10.1097/01.ta.0000196003.41799.41

Cited by 13 publications

(8 citation statements)

References 39 publications

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“…Of the in-hospital deaths associated with traumatic injuries 48-61% have a DNR order in place. 9, 13, 23 In the present study 36% of the deaths were preceded by a DNR order. This difference is, in part, a result of the study population, those patients requiring a transfusion and presumed to be hemorrhaging and thus at risk for an early death.…”

Section: Discussionsupporting

confidence: 46%

“…The reported mortality rates of trauma patients with a DNR order ranges from 40 to 94%. 9, 10, 13, 14 In the PROMMTT study the mortality was 99% for patients with a DNR order. Of the in-hospital deaths associated with traumatic injuries 48-61% have a DNR order in place.…”

Section: Discussionmentioning

confidence: 99%

“…In the PROMMTT study, the use and timing of DNR orders appeared to be similar to those in the overall trauma population. 9, 10, 13 To assess the impact of initiation of DNR orders on analysis of the effect of increased ratios of plasma and platelets to red cells on survival we determined the frequency and timing for patients with DNR orders in the PROMMTT study. While the initiation of DNR orders occurred later in the course of care, death happened shortly thereafter.…”

Section: Discussionmentioning

confidence: 99%

“…11, 12 The average time of implementation of a DNR order is 24-48 hours after admission in trauma patients. 9, 10, 13 Furthermore the mortality risk in trauma patients with these orders in place is 43% to 94%. 9, 10, 13, 14 Whereas the mortality risk with a DNR in place is 23 to 37% for general surgery patients, but in some cases may be as high as 82%.…”

Section: Introductionmentioning

confidence: 99%

“…9, 10, 13 Furthermore the mortality risk in trauma patients with these orders in place is 43% to 94%. 9, 10, 13, 14 Whereas the mortality risk with a DNR in place is 23 to 37% for general surgery patients, but in some cases may be as high as 82%. 15-17 Franklin et al suggested that because of the presence of DNR orders after traumatic injury that medical care could not have been expected to impact 62% of trauma deaths.…”

Section: Introductionmentioning

confidence: 99%

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

Wade

Junco

Fox

et al. 2013

Journal of Trauma and Acute Care Surgery

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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.

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Section: Discussionsupporting

confidence: 46%