Korean J Crit Care Med.  2016 Aug;31(3):229-235. 10.4266/kjccm.2016.00178.

Effect of Timing of Do-Not-Resuscitate Orders on the Clinical Outcome of Critically Ill Patients

• Baek MS
• Koh Y
• Hong SB
• Lim CM
• Huh JW

• KMID: 2350907
• DOI: http://doi.org/10.4266/kjccm.2016.00178

Abstract

BACKGROUND
Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situations. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient distress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU.
METHODS
We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission.
RESULTS
Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001).
CONCLUSIONS
Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further studies are needed to clarify the guideline for end-of-life care in critically ill patients.

Keyword

resuscitation orders; intensive care units; cardiopulmonary resuscitation; advance directives

MeSH Terms

Advance Directives
Cardiopulmonary Resuscitation
Consent Forms
Critical Illness*
Hospital Mortality
Humans
Intensive Care Units
Resuscitation Orders*
Retrospective Studies
Shock, Septic

Figure

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  Fig. 1. Flowchart of enrolled patients in this study. early DNR orders: implemented within 48 h of ICU admission; late DNR orders: implemented more than 48 h after ICU admission; ICU: intensive care unit; DNR: do-notresuscitate.

Reference

References

1. Stevens MB. Withholding resuscitation. Am Fam Physician. 1986; 33:207–12.

2. Phua J, Joynt GM, Nishimura M, Deng Y, Myatra SN, Chan YH, et al. Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia. JAMA Intern Med. 2015; 175:363–71.

3. Dzeng E, Colaianni A, Roland M, Chander G, Smith TJ, Kelly MP, et al. Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life. JAMA Intern Med. 2015; 175:812–9.

4. Huynh TN, Kleerup EC, Raj PP, Wenger NS. The opportunity cost of futile treatment in the intensive care unit. Crit Care Med. 2014; 42:1977–82.

5. Huynh TN, Kleerup EC, Wiley JF, Savitsky TD, Guse D, Garber BJ, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013; 173:1887–94.

6. Ferrell BR. Understanding the moral distress of nurses witnessing medically futile care. Oncol Nurs Forum. 2006; 33:922–30.

7. Weng L, Joynt GM, Lee A, Du B, Leung P, Peng J, et al. Attitudes towards ethical problems in critical care medicine: the Chinese perspective. Intensive Care Med. 2011; 37:655–64.

8. Buckley TA, Joynt GM, Tan PY, Cheng CA, Yap FH. Limitation of life support: frequency and practice in a Hong Kong intensive care unit. Crit Care Med. 2004; 32:415–20.

9. Marrie TJ, Fine MJ, Kapoor WN, Coley CM, Singer DE, Obrosky DS. Community-acquired pneumonia and do not resuscitate orders. J Am Geriatr Soc. 2002; 50:290–9.

10. Bradford MA, Lindenauer PK, Wiener RS, Walkey AJ. Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock. Crit Care Med. 2014; 42:2042–7.

11. Teres D. Trends from the United States with end of life decisions in the intensive care unit. Intensive Care Med. 1993; 19:316–22.

12. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008; 36:953–63.

13. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013; 41:580–637.

14. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010; 340:c1345.

15. Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007; 35:1530–5.

16. Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med. 2010; 38:S518–22.

17. Beauchamp T, Childress J. Principles of Biomedical Ethics. 7th ed. Oxford: Oxford University Press;2013.

18. Luce JM. Is the concept of informed consent applicable to clinical research involving critically ill patients? Crit Care Med. 2003; 31:S153–60.

19. The AM, Hak T, Koëter G, van Der Wal G. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ. 2000; 321:1376–81.

20. Searight HR, Gafford J. Cultural diversity at the end of life: issues and guidelines for family physicians. Am Fam Physician. 2005; 71:515–22.

21. Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. Ethnicity and attitudes toward patient autonomy. JAMA. 1995; 274:820–5.

22. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003; 290:790–7.

23. Thompson BT, Cox PN, Antonelli M, Carlet JM, Cassell J, Hill NS, et al. Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med. 2004; 32:1781–4.