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Neurological Impact of DNR Decisions After Cardiac Arrest
Study Questions:
Are patients’ decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest aligned with their expected prognosis?
Methods:
The study cohort was comprised of 26,327 patients from the Get With The Guidelines–Resuscitation Study. All patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest were included. The study investigators used a previously validated tool to calculate each patient’s likelihood of favorable neurological survival (i.e., without severe neurological disability). They examined the proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival.
Results:
The study investigators found that 22.6% (n = 5,944) of patients had DNR orders within 12 hours of ROSC (95% confidence interval [CI], 22.1%-23.1%), while 77.4% (n = 20,383) did not (95% CI, 76.9%-77.9%). Patients with DNR orders were older, were more frequently of white race, were more likely to have baseline neurological disability (cerebral performance category, >1), and had higher rates of comorbidities (all p < 0.05) than patients without DNR orders. The rate of favorable neurological survival was 24.0% (95% CI, 23.5%-24.5%) among patients with ROSC. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (p for both trends < 0.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5%; 95% CI, 29.9%-31.1%) than it was for those with DNR orders (1.8%; 95% CI, 1.6%-2.0%). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis.
Conclusions:
The study authors concluded that although DNR orders after in-hospital cardiac arrest were generally aligned with patients’ likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders.
Perspective:
This is an important study because it highlights the impact of DNR orders on neurological outcomes. These findings should help the practicing physician to better manage the expectations of patients and their relatives before they opt for DNR status. This study suggests that more needs to be done regarding goals of care in patients with poor prognosis; one option is to involve the palliative team to help make such crucial decisions.
Keywords: Heart Arrest, Heart Failure, Geriatrics, Neurologic Manifestations, Palliative Care, Patient Care Planning, Prognosis, Resuscitation, Resuscitation Orders, Survival
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