Many Critically Ill Patients Lack ‘Do Not Resuscitate’ Orders

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Most people who’ve survived a cardiac arrest in the hospital don’t have “do not resuscitate” (DNR) orders, even if they have a poor prognosis, a new study reports.

Fewer than one in four of all cardiac arrest patients had a DNR order prepared within 12 hours of their cardiac arrest, the study found. The numbers were only somewhat higher in patients with the worst prognosis even though their likelihood of recovery was very poor.

A cardiac arrest “is a serious and life-altering event that should prompt adequate and informed decisions about prognosis and goals of care,” said study lead author Dr. Timothy Fendler, a cardiology fellow at Saint Luke’s Mid America Heart Institute in Kansas City, Mo. “These results imply that there could be better alignment between prognosis and decisions that place the patient’s wishes, safety and quality of life at the forefront.”

At issue: Should patients undergo cardiopulmonary resuscitation (CPR) — which can be painful, harmful and sometimes fruitless — when they’re already critically ill and their lungs or heart stops working?

There’s no correct answer to the question of whether a patient prefers to be resuscitated, Fendler said. But all patients should be asked about their preference when they’re admitted to a hospital, he said.

Then, if they “experience a traumatic or life-threatening event such as cardiac arrest, clinicians, families and health care staff know the patient’s wishes and can execute them accordingly,” he explained.

When patients can’t make their wishes known, families step in.

The new study aimed to understand the connections, or lack of them, between prognosis and DNR orders after cardiac arrest. “To our knowledge, this is the first study of its kind to assess how well the chance for good recovery is associated with patients’ decisions,” Fendler said.

The study authors looked at more than 26,000 cases of patients who survived cardiac arrests at more than 400 U.S. hospitals from 2006-2012. The authors said that while TV hospital shows may have unrealistically altered people’s expectations, the truth is, it’s difficult for people to survive cardiac arrests anywhere, even in the hospital. Those who do survive often suffer from severe problems, such as brain deficits, the study said.

Researchers found that nearly 23 percent of the patients had DNR orders on file within 12 hours after their cardiac arrest. Among the patients with the best neurological prognosis, only 7 percent had such orders on file, even though about a third of them could expect not to do well neurologically.

Of the patients with the worst prognosis, slightly more than a third had a DNR order on file, even though only 4 percent were expected to do well neurologically, the study noted.

Patients with orders on file stayed in the hospital for shorter times, and their care cost less, the researchers found.

One expert saw similarities in his own practice.

“The study results resonate with my personal experiences and those of many emergency and critical care providers,” said Dr. Benjamin Abella, clinical research director with the Center for Resuscitation Science at the University of Pennsylvania in Philadelphia.

“Hopefully, the study can serve as a wake-up call that DNR discussions should occur early and often following cardiac arrest, and that these discussions should be based on the survival potential for individual patients,” said Abella, who was not involved with the research.

However, DNR orders aren’t appropriate for all patients, he cautioned. Aggressive care can be appropriate for patients with a good prognosis, he said.

Whatever the case, Abella said, “these discussions are best held before patients become critically ill in the hospital.”

The study appears in the Sept. 22/29 issue of the Journal of the American Medical Association.

More information

For more about DNR orders, try the American Academy of Family Physicians.

Source: HealthDay

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