HHS Public Access Author manuscript Author Manuscript
JAMA. Author manuscript; available in PMC 2016 January 05. Published in final edited form as: JAMA. 2015 September 22; 314(12): 1264–1271. doi:10.1001/jama.2015.11069.
Alignment of Do-Not-Resuscitate Status with Patients' Likelihood of Favorable Neurological Survival After In-hospital Cardiac Arrest
Author Manuscript
Timothy J. Fendler, MD, MS1, John A. Spertus, MD, MPH1, Kevin F. Kennedy, MS1, Lena M. Chen, MD, MS2, Sarah M. Perman, MD, MSCE3, and Paul S. Chan, MD, MSc1 for the American Heart Association's Get With the Guidelines-Resuscitation Investigators Timothy J. Fendler: [email protected]; John A. Spertus: [email protected]; Kevin F. Kennedy: [email protected]; Lena M. Chen: [email protected]; Sarah M. Perman: [email protected]; Paul S. Chan: [email protected] 1Department
of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
2Department
of Medicine, University of Michigan, Ann Arbor, MI
3Department
of Emergency Medicine, University of Colorado School of Medicine, Denver, CO
Abstract Importance—After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.
Author Manuscript
Objective—To assess whether patients' decisions for Do-Not-Resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis. Design, Setting, Participants—Within Get With The Guidelines®-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 U.S. hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (i.e., without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined. Exposure—DNR orders within 12 hours of ROSC. Main Outcome—Likelihood of favorable neurological survival.
Author Manuscript
Send correspondence and reprint requests to: Timothy Fendler, MD, Saint Luke's Mid-America Heart Institute, 4401 Wornall Rd., SLNI Suite #5603, Kansas City, MO 64111, Phone: (816) 932-5475, Fax: (816) 932-5613, [email protected]. Disclosures: None of the authors have any relevant conflicts of interest or disclosures. Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Authorship: Drs. Fendler and Chan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Design and Conduct of the Study: Fendler, Chan Collection, Management, Analysis, and Interpretation of the Data: Fendler, Spertus, Kennedy, Chen, Perman, Chan Preparation, Review, or Approval of the Manuscript: Fendler, Spertus, Kennedy, Chen, Perman, Chan Decision to Submit the Manuscript for Publication: Fendler, Chan
Fendler et al.
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Author Manuscript
Results—Overall, 5,944 (22.6% [95% CI: 22.1%, 23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P 1). In addition, they had higher rates of pre-existing conditions including hypotension, respiratory insufficiency, renal insufficiency, hepatic insufficiency, metabolic or electrolyte abnormalities, and pneumonia. Finally, patients with DNR orders after ROSC were more likely to have cardiac arrest rhythms associated with lower overall survival (e.g., pulseless electrical activity) and longer resuscitation times. Relationship Between DNR Status and Expected Prognosis The rate of favorable neurological survival was 24.0% (95% CI: 23.5%, 24.5%) among patients with ROSC. When patients were stratified by prognosis deciles, this rate was 64.7% in decile 1 and decreased to 4.0% in decile 10 (P for trend
JAMA. Author manuscript; available in PMC 2016 January 05. Published in final edited form as: JAMA. 2015 September 22; 314(12): 1264–1271. doi:10.1001/jama.2015.11069.
Alignment of Do-Not-Resuscitate Status with Patients' Likelihood of Favorable Neurological Survival After In-hospital Cardiac Arrest
Author Manuscript
Timothy J. Fendler, MD, MS1, John A. Spertus, MD, MPH1, Kevin F. Kennedy, MS1, Lena M. Chen, MD, MS2, Sarah M. Perman, MD, MSCE3, and Paul S. Chan, MD, MSc1 for the American Heart Association's Get With the Guidelines-Resuscitation Investigators Timothy J. Fendler: [email protected]; John A. Spertus: [email protected]; Kevin F. Kennedy: [email protected]; Lena M. Chen: [email protected]; Sarah M. Perman: [email protected]; Paul S. Chan: [email protected] 1Department
of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
2Department
of Medicine, University of Michigan, Ann Arbor, MI
3Department
of Emergency Medicine, University of Colorado School of Medicine, Denver, CO
Abstract Importance—After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.
Author Manuscript
Objective—To assess whether patients' decisions for Do-Not-Resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis. Design, Setting, Participants—Within Get With The Guidelines®-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 U.S. hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (i.e., without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined. Exposure—DNR orders within 12 hours of ROSC. Main Outcome—Likelihood of favorable neurological survival.
Author Manuscript
Send correspondence and reprint requests to: Timothy Fendler, MD, Saint Luke's Mid-America Heart Institute, 4401 Wornall Rd., SLNI Suite #5603, Kansas City, MO 64111, Phone: (816) 932-5475, Fax: (816) 932-5613, [email protected]. Disclosures: None of the authors have any relevant conflicts of interest or disclosures. Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Authorship: Drs. Fendler and Chan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Design and Conduct of the Study: Fendler, Chan Collection, Management, Analysis, and Interpretation of the Data: Fendler, Spertus, Kennedy, Chen, Perman, Chan Preparation, Review, or Approval of the Manuscript: Fendler, Spertus, Kennedy, Chen, Perman, Chan Decision to Submit the Manuscript for Publication: Fendler, Chan
Fendler et al.
Page 2
Author Manuscript
Results—Overall, 5,944 (22.6% [95% CI: 22.1%, 23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P 1). In addition, they had higher rates of pre-existing conditions including hypotension, respiratory insufficiency, renal insufficiency, hepatic insufficiency, metabolic or electrolyte abnormalities, and pneumonia. Finally, patients with DNR orders after ROSC were more likely to have cardiac arrest rhythms associated with lower overall survival (e.g., pulseless electrical activity) and longer resuscitation times. Relationship Between DNR Status and Expected Prognosis The rate of favorable neurological survival was 24.0% (95% CI: 23.5%, 24.5%) among patients with ROSC. When patients were stratified by prognosis deciles, this rate was 64.7% in decile 1 and decreased to 4.0% in decile 10 (P for trend
