A patient coming in to the ICU with a Do Not Resuscitate (DNR) order in place is at significant increased risk of dying within 28 days of being admitted, according to a retrospective analysis of patients admitted to five ICUs between 2001 and 2008 at Beth Israel Deaconess Medical Center in Boston, MA.
The study's authors found that specific patient groups were especially vulnerable: women, surgical, mechanically ventilated and patients with oncologic diseases.
The authors theorize that doctors interpret the DNR order more broadly to mean fewer treatments and medicines. Its original meaning is a specific order not to attempt CPR in certain circumstances.
The study was led by Dr. Lior Fuchs, a senior physician in the Medical Intensive Care Unit at Soroka University Medical Center and Prof. Victor Novack, a professor of internal medicine in BGU's Faculty of Health Sciences (FOHS) and an advisor to the dean for Clinical Research. Novack is the incumbent of the Gussie Krupp Chair in Internal Medicine in the FOHS at BGU. He is also the head of the Clinical Research Center and Research Authority at Soroka. Novack also holds a dual appointment in the Department of Anesthesia, Critical Care and Pain Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School.
19,007 patients entered the ICU between 2001 and 2008. Of those, 1,239 had a DNR order on the first day of ICU admission and survived the first 48 hours. The authors compared their treatment to 2,402 similar patients (age, type of ICU and 28 day probability of death) who did not have a DNR order on day one.
“Looking at 28 day mortality, the rates were significantly higher in the DNR group (33.9% vs. 18.4%). Moreover, even within the group with a low probability of death, patients with DNR orders had five-fold increases in 28 day mortality from 3% to 17%. This is the first study to report on DNR association with mortality in the cohort of patients admitted to the ICUs," says Novack, “and the discrepancy in understanding the DNR order by the treatment team could be partially responsible for the observed association."
The authors found that patients with DNR received less mechanical ventilation, fewer radiological investigations and had fewer medications prescribed. Other studies have shown that DNR patients receive fewer heart failure interventions as well.
Novack and his colleagues believe the problem may lie with doctors confusing DNR orders and patients' desires for end-of-life care and therefore the doctors are less inclined to intervene in life threatening situations. The team recommend clarifying such matters before treatment to align patients' wishes and doctors' level of care.
The study was published online in June 2017 in Critical Care Medicine.
"Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU"
Fuchs L, Anstey M, Feng M, Toledano R, Kogan S, Howell MD, Clardy P, Celi L, Talmor D, Novack V.
