Predictors to forgo resuscitative effort during Covid-19 critical illness at the height of the pandemic : A retrospective cohort study

• Published in: Palliative medicine Vol. 35; no. 8; pp. 1519 - 1524
• Main Authors: Mesfin, Nathan, Fischman, Alexandra, Garcia, Michael A, Johnson, Shelsey, Parikh, Raj, Wiener, Renda Soylemez
• Format: Journal Article
• Language: English
• Published: London, England SAGE Publications 01.09.2021; Sage Publications Ltd
• Subjects: Cardiopulmonary resuscitation; Chemical analysis; Clinical decision making; Cohort analysis; Communication; Coronaviruses; COVID-19; CPR; Decision making; End of life decisions; Ethnic groups; Ethnicity; Hospitalization; Illnesses; Intensive care; Mechanical ventilation; Medical prognosis; Minority groups; Multivariate analysis; Objectives; Palliative care; Pandemics; Race; Racial differences; Resuscitation; Severe acute respiratory syndrome coronavirus 2; Uncertainty; Underserved populations; Ventilation; Verbal communication; health disparity; SARS-CoV-2; Covid-19; code status; Do-not-resuscitate
• ISSN: 0269-2163; 1477-030X
• DOI: 10.1177/02692163211022622

Background: Early in the Covid-19 pandemic, there was uncertainty regarding critical illness prognosis and challenges to traditional face-to-face family meetings. Ethnic minority populations have suffered disproportionately worse outcomes during the pandemic, which may in part relate to differences in end-of-life decision-making. Aim: Characterize patterns of and factors associated with decisions to forgo resuscitative efforts, as measured by do-not-resuscitate orders, during critical illness with Covid-19. Design: Retrospective cohort with medical record abstraction. Setting/participants: Adult patients diagnosed with SARS-Cov-2 virus via polymerase chain reaction and admitted to the intensive care unit at an academic hospital, which cares for the city’s underserved communities, between March 1 and June 7, 2020 who underwent invasive mechanical ventilation for at least 48 hours. Results: In this cohort (n = 155), 45% were black people, and 51% spoke English as their primary language. Median time to first goals-of-care conversation was 3.9 days (IQR 1.9–7.6) after intensive care unit admission. Overall 61/155 patients (39%) transitioned to do-not-resuscitate status, and 50/62 (82%) patients who died had do-not-resuscitate orders. Multivariate analysis shows age and palliative care involvement as the strongest predictors of decision to instate do-not-resuscitate order. There was no association between race, ethnicity, or language and decisions to forego resuscitation. Conclusions: During this time of crisis and uncertainty with limited resources and strained communication, time to first goals of care conversation was shorter than in pre-pandemic studies, but rates of foregoing resuscitation remained similar, with no differences observed by race, ethnicity, or language. This study suggests that early palliative care involvement and non-traditional communications, including videoconferencing, to facilitate goals of care conversations could have mitigated potential disparities in end-of-life decision making patterns during the pandemic.