The epidemiology of do-not-resuscitate orders in patients with trauma: a community level one trauma center observational experience

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

David Bar-Or³  Matthew Carrick⁴  Charles W Mains³  Denetta S Slone³  Alessandro Orlando²  Patrick J Offner¹  Kristin Salottolo² 

[1] Trauma Services Department, St. Anthony Hospital, Lakewood 80228, CO, USA;Trauma Research Department, St. Anthony Hospital, Lakewood 80228, CO, USA;Rocky Vista University, Aurora 80011, CO, USA;Trauma Services Department, Medical Center of Plano, Plano 75075, TX, USA

关键词: Elderly;    Outcomes;    Epidemiology;    Trauma;    Do-Not-Resuscitate;   

Others  :  1132262
DOI  :  10.1186/s13049-015-0094-2

 received in 2014-11-11, accepted in 2015-01-19,  发布年份 2015

【 摘 要 】

Background

Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients.

Methods

We included all adults with trauma to a community Level I Trauma Center over 6 years (2008–2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications).

Results

Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3–8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay.

Conclusions

Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma.

【 授权许可】

   
2015 Salottolo et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]Cherniack EP: Increasing use of DNR orders in the elderly worldwide: whose choice is it? J Med Ethics 2002, 28:303-7.
• [2]Silveira MJ, Kim SY, Langa KM: Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010, 362:1211-8.
• [3]Wenger NS, Pearson ML, Desmond KA, Kahn KL: Changes over time in the use of do not resuscitate orders and the outcomes of patients receiving them. Med Care 1997, 35:311-9.
• [4]Greco PJ, Schulman KA, Lavizzo-Mourey R, Hansen-Flaschen J: The patient self-determination Act and the future of advance directives. Ann Intern Med 1991, 115:639-43.
• [5]Wenger NS, Pearson ML, Desmond KA, Brook RH, Kahn KL: Outcomes of patients with do-not-resuscitate orders. Toward an understanding of what do-not-resuscitate orders mean and how they affect patients. Arch Intern Med 1995, 155:2063-8.
• [6]Curtis JR, Park DR, Krone MR, Pearlman RA: Use of the medical futility rationale in do-not-attempt-resuscitation orders. JAMA 1995, 273:124-8.
• [7]Boyd K, Teres D, Rapoport J, Lemeshow S: The relationship between age and the use of DNR orders in critical care patients. Evidence for age discrimination. Arch Intern Med 1996, 156:1821-6.
• [8]Hakim RB, Teno JM, Harrell FE Jr, Knaus WA, Wenger N, Phillips RS, et al.: Factors associated with do-not-resuscitate orders: patients’ preferences, prognoses, and physicians’ judgments. SUPPORT investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. Ann Intern Med 1996, 125:284-93.
• [9]Chen JL, Sosnov J, Lessard D, Goldberg RJ: Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J 2008, 156:78-84.
• [10]Silvennoinen K, Meretoja A, Strbian D, Putaala J, Kaste M, Tatlisumak T: Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage. Int J Stroke 2014, 9:53-8.
• [11]Beach MC, Morrison RS: The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc 2002, 50:2057-61.
• [12]Mirarchi FL, Costello E, Puller J, Cooney T, Kottkamp N: TRIAD III: nationwide assessment of living wills and do not resuscitate orders. J Emerg Med 2012, 42:511-20.
• [13]Huang YC, Huang SJ, Ko WJ: Survey of do-not-resuscitate orders in surgical intensive care units. J Formos Med Assoc 2010, 109:201-8.
• [14]Kazaure H, Roman S, Sosa JA: High mortality in surgical patients with do-not-resuscitate orders: analysis of 8256 patients. Arch Surg 2011, 146:922-8.
• [15]Scarborough JE, Pappas TN, Bennett KM, Lagoo-Deenadayalan S: Failure-to-pursue rescue: explaining excess mortality in elderly emergency general surgical patients with preexisting “do-not-resuscitate” orders. Ann Surg 2012, 256:453-61.
• [16]Saager L, Kurz A, Deogaonkar A, You J, Mascha EJ, Jahan A, et al.: Pre-existing do-not-resuscitate orders are not associated with increased postoperative morbidity at 30 days in surgical patients. Crit Care Med 2011, 39:1036-41.
• [17]Jayes RL, Zimmerman JE, Wagner DP, Knaus WA: Variations in the use of do-not-resuscitate orders in ICUS. Findings from a national study. Chest 1996, 110:1332-9.
• [18]Rapoport J, Teres D, Lemeshow S: Resource use implications of do not resuscitate orders for intensive care unit patients. Am J Respir Crit Care Med 1996, 153:185-90.
• [19]Eachempati SR, Hydo L, Shou J, Barie PS: Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery. J Trauma 2006, 60:193-7. discussion 197–198
• [20]Brizzi M, Abul-Kasim K, Jalakas M, Selariu E, Pessah-Rasmussen H, Zia E: Early do-not-resuscitate orders in intracerebral haemorrhage; frequency and predictive value for death and functional outcome. A retrospective cohort study. Scand J Trauma Resusc Emerg Med 2012, 20:36. BioMed Central Full Text
• [21]Hemphill JC 3rd, Newman J, Zhao S, Johnston SC: Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke 2004, 35:1130-4.
• [22]Silvennoinen K, Meretoja A, Strbian D, Putaala J, Kaste M, Tatlisumak T: Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage. Int J, Stroke; 2013.
• [23]Shepardson LB, Youngner SJ, Speroff T, Rosenthal GE: Increased risk of death in patients with do-not-resuscitate orders. Med Care 1999, 37:727-37.
• [24]Baker DW, Einstadter D, Husak S, Cebul RD: Changes in the use of do-not-resuscitate orders after implementation of the Patient Self-Determination Act. J Gen Intern Med 2003, 18:343-9.
• [25]Wenger NS, Pearson ML, Desmond KA, Harrison ER, Rubenstein LV, Rogers WH, et al.: Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment. Arch Intern Med 1995, 155:2056-62.
• [26]Torke AM, Sachs GA, Helft PR, Petronio S, Purnell C, Hui S, et al.: Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker. J Am Geriatr Soc 2011, 59:1326-31.
• [27]Thompson HJ, Rivara FP, Jurkovich GJ, Wang J, Nathens AB, MacKenzie EJ: Evaluation of the effect of intensity of care on mortality after traumatic brain injury. Crit Care Med 2008, 36:282-90.
• [28]Turgeon AF, Lauzier F, Simard JF, Scales DC, Burns KE, Moore L, et al.: Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ 2011, 183:1581-8.
• [29]Nathens AB, Rivara FP, Wang J, Mackenzie EJ, Jurkovich GJ: Variation in the rates of do not resuscitate orders after major trauma and the impact of intensive care unit environment. J Trauma 2008, 64:81-8. discussion 88–91
• [30]Wade CE, del Junco DJ, Fox EE, Cotton BA, Cohen MJ, Muskat P, et al.: Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates: an evaluation using the PROMMTT study. J Traum Acute Care Surg 2013, 75:S89-96.
• [31]Adams SD, Cotton BA, Wade CE, Kozar RA, Dipasupil E, Podbielski JM, et al.: Do not resuscitate status, not age, affects outcomes after injury: an evaluation of 15,227 consecutive trauma patients. J Traum Acute Care Surg 2013, 74:1327-30.
• [32]Emergency Medical and Trauma Services Section: Colorado Trauma Registry Inclusion/Exclusion Criteria [http:/ / www2.cde.state.co.us/ artemis/ hemonos/ he193108t692011internet/ he193108t69201101internet.pdf] webciteEmergency Medical and Trauma Services Section: Colorado Trauma Registry Inclusion/Exclusion Criteria 2011. http://www2.cde.state.co.us/artemis/hemonos/he193108t692011internet/he193108t69201101internet.pdf . Access date: January 27, 2015
• [33]Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987, 40:373-83.
• [34]The older population: 2010 [http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf]. Access date: November 6th, 2014.
• [35]Mosenthal AC, Murphy PA: Trauma care and palliative care: time to integrate the two? J Am Coll Surg 2003, 197:509-16.
• [36]Kelly AG, Zahuranec DB, Holloway RG, Morgenstern LB, Burke JF: Variation in do-not-resuscitate orders for patients with ischemic stroke: implications for national hospital comparisons. Stroke 2014, 45:822-7.
• [37]Buchman TG, Cassell J, Ray SE, Wax ML: Who should manage the dying patient?: Rescue, shame, and the surgical ICU dilemma. J Am Coll Surg 2002, 194:665-73.