Impact of Early Do-Not-Attempt-Resuscitation Orders on Procedures and Outcomes of Severe Sepsis

• Published in: Journal of critical care Vol. 36; pp. 134 - 139
• Main Authors: Sarkari, Neza N., BS, Perman, Sarah M., MD, MSCE, Ginde, Adit A., MD, MPH
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.12.2016; Elsevier Limited
• Subjects: Adolescent; Adult; Advance Directives; Age Factors; Aged; Aged, 80 and over; Alcohol; California; Cancer; Catheterization, Central Venous - utilization; Critical Care; Cross-Sectional Studies; Databases, Factual; Diabetes; Emergency Service, Hospital; Ethnicity; Family income; Female; Heart failure; Hemodialysis; Hispanic people; Hospital Mortality; Hospitalization; Hospitals; Humans; Liver diseases; Lung diseases; Lymphoma; Male; Medical futility; Medicare; Metastasis; Middle Aged; Mortality; Nursing; Patients; Procedures; Renal Dialysis - utilization; Respiration, Artificial - utilization; Resuscitation Orders; Rural Population; Sepsis; Sepsis - therapy; Studies; Surgical Procedures, Operative - utilization; Time Factors; Variables; Ventilation; Young Adult; Medical Futility; Sepsis; Procedures; Resuscitation Orders; Hospital Mortality; Advance Directives; Advance directives; Hospital mortality; Resuscitation orders; Medical futility
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2016.06.030

Abstract Purpose Do-not-attempt-resuscitation (DNAR) orders are common in severe sepsis but the impact on clinical care is not known. Our primary objective was to determine the impact of early DNAR orders on in-hospital mortality and performance of key interventional procedures among severe sepsis hospitalizations. Our secondary objective was to further investigate what patient characteristics within the sepsis DNAR population affected outcomes. Methods Using the 2010–2011 California State Inpatient Dataset, we analyzed hospitalizations for adults admitted through the emergency department with severe sepsis. Our primary predictor was a DNAR order and our outcomes were in-hospital mortality and performance of interventional procedures. Results Visits with early DNAR orders accounted for 20.3% of severe sepsis hospitalizations. An early DNAR order was a strong, independent predictor of higher in-hospital mortality (OR 4.03; 95%CI, 3.88–4.19) and lower performance of critical procedures: central venous line (OR 0.70), mechanical ventilation (OR 0.80), hemodialysis (OR 0.61), and major operative procedure (OR 0.46). Among those with early DNAR orders, older age and rural location were the strongest predictors for a lack of interventional procedures. Conclusion Though DNAR orders are not synonymous with “do not treat,” they may unintentionally limit aggressive treatment for severe sepsis patients, especially in older adults.