Impact of survival probability, life expectancy, quality of life and patient preferences on do-not-attempt-resuscitation orders in a hospital

doi:10.1016/S0300-9572(98)00097-5

Resuscitation

Volume 39, Issues 1–2, November 1998, Pages 15-21

https://doi.org/10.1016/S0300-9572(98)00097-5 Get rights and content

Abstract

Consensus exists that a do-not-attempt-resuscitation order (DNAR) is appropriate if a resuscitation attempt is futile. Less agreement exists when this point is reached. We investigated the influence of three major considerations for in-hospital DNAR orders: expected survival probability after resuscitation, prospects of the patients' current condition without a cardiac arrest and the patients' autonomous decision not to want resuscitation. We calculated an expected survival probability according to two multi-morbidity prediction scores for each patient, assuming the event of cardiac arrest. The prospects of the current condition without a cardiac arrest was estimated by the patients' physician, in terms of life expectancy and quality of life (level of dependency after discharge and pain). The patients' preference was documented from the medical records. A total of 470 patients were included in the study. Fifty-eight patients (12%) had a DNAR-order, 11 of these patients (19%) wanted no resuscitation. The patients' prospects (life expectancy, dependency after discharge), and age proved to be independently associated with the presence of a DNAR order. The odds ratio (OR) for the presence of a DNAR order was 37 (CL 14–107) for an estimated life expectancy less than 3 months, 13 (CL 4–41) for a life in a nursing home and four (CL 2–12) for an age of 80 years and older. Expected survival probability after resuscitation and pain were not independently associated with a DNAR order. We conclude that resuscitation is considered futile on the basis of the patients' age and prospects without cardiac arrest and that the impact of expected survival probability on these decisions is small.

Introduction

Doctors can decide unilaterly on a DNAR order when no survival is expected [1]. However, they should seek consensus from their patients about such an order if survival is possible, but the prospects of the current condition without a cardiac arrest are poor. Regardless of survival probability or prospects, patients can also autonomously decide not to be resuscitated, if they are mentally and emotionally competent, and well informed [2].

Survival after resuscitation is currently studied in relation to morbidities which are present before the cardiac arrest. One single diagnosis is, however, often not enough to be certain about survival prospects 3, 4. For this reason, multi-morbidity scores are developed 5, 6. These scores can be useful in clinical practice, because doctors have difficulty in estimating the survival probabilities for various medical conditions [7].

Even when a patient has a reasonable chance of survival, resuscitation should not be applied without considering the prospects of the patient without a cardiac arrest. Resuscitation will not improve the prospects of the current condition of the patient, and at best the prospects will remain the same. If the prospects of the current condition are poor and a cardiac arrest should occur, the patient may survive the resuscitation but die from the underlying condition afterwards. Therefore, a poor prospect before cardiac arrest, in terms of life expectancy and quality of life, can be thus also a reason for a DNAR order [8].

Although several factors have been associated with the presence of a DNAR order, such as age, ethnic background, gender, and diagnosis 9, 10, 11, 12, 13, 14, 15, there is little information about the influence of the expected survival probability after resuscitation and the prospects without a cardiac arrest on such orders. The objective of this study was (a) to assess the occurrence of autonomous decisions by patients not to want resuscitation, (b) to determine the impact of the expected survival probability after resuscitation and (c) the prospects without cardiac arrest on actual DNAR orders in a hospital population.

Section snippets

Setting

The study was performed in the Academic Medical Centre, a tertiary care and university teaching hospital (1030 beds, 26 000 admissions per year) between February 1997 and June 1997. The hospital policy is to always initiate resuscitation unless there is a DNAR order. The medical records include a special form for treatment limitations, on which is marked whether or not cardiopulmonary resuscitation should be attempted. The form also indicates which other medical treatments, such as intensive

Results

A total of 470 patients were included in the study (243 women and 227 men). The median age (S.D.) was 59 years (17). Fifty-eight patients (12%) had a DNAR-order; in 52 patients (90%) these orders also indicated the withholding of other types of treatment, whereas 6 (10%) only concerned withholding resuscitation. The time (S.D.) between hospital admission and issuing a DNAR order was 10 days (13), 14 orders (24%) were established on the first day of admission. Twelve of the 58 patients with a

Discussion

In this study, the prospects without a cardiac arrest (estimated life expectancy and dependency), and age had an important independent impact on the presence of a DNAR orders. Expected survival probability after resuscitation appeared to have no influence on such orders. Nineteen percent of patients with a DNAR order autonomously decided not to want resuscitation should a cardiac arrest occur.

These findings are based on a review of medical records in our hospital, and show the main determinants

Acknowledgements

Supported by a grant from the Netherlands Heart Foundation.

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