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Most Cardiac Arrest Inpatients with Poor Prognosis Don’t Opt for DNRs

KANSAS CITY – Do-not-resuscitate (DNR) orders are designed for use by patients with a poor prognosis for favorable neurological survival, such as being revived without severe cognitive disability.

In fact, that’s the way it generally works for those who survive an in-hospital cardiac arrest: The presence of a DNR typically is in line with their prognosis, according to a study published recently in the Journal of the American Medical Association.

Yet the study led by researchers from Saint Luke's Mid America Heart Institute in Kansas City also found that nearly two-thirds of patients least likely to have a favorable neurological survival did not have DNR orders.

"Among patients with a low likelihood of favorable neurological survival after in-hospital cardiac arrest, our findings highlight the potential to improve DNR decision making,” the authors write.

Background information in the article notes that in-hospital cardiac arrest affects nearly 200,000 patients in the United States annually, with fewer than 20% having favorable neurological survival.

Using the Get With The Guidelines-Resuscitation registry, the research team 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. Each patient's likelihood of favorable neurological survival was calculated, and the proportion of patients with DNR orders within each prognosis score group and the association between DNR status and actual favorable neurological survival were examined.

Results indicate that 23% of the patients had DNR orders within 12 hours of ROSC, usually older patients with a high rate of comorbidities. While 7% of patients with the best prognosis had DNR orders, even though their predicted rate of favorable neurological survival was 65%, 36% of the patients with the worst expected outcomes opted against resuscitation, despite an expected favorable neurological survival rate of just 4%. That pattern continued after 24 hours, 72 hours, and five days past ROSC, according to the study.

Study authors also point out that “patients who had DNR orders despite a good prognosis had significantly lower survival and less resource use than patients without DNR orders who had a similar prognosis after ROSC.”

In an accompanying editorial, JAMA associate editor Derek C. Angus, MD, MPH, of the University of Pittsburgh, notes, "In summary, when a cardiac arrest occurs in hospital, healthcare teams are good at rushing in to provide robust resuscitative effort.

"However, after successful ROSC, just as after the initial response to any disaster, it is clear the work has only just begun. Hopefully in the future, standardized delivery of high-quality evidence-based resuscitation guidelines for cardiac arrest will be followed by equally high-quality standard approaches to ensure patients and families are supported optimally, regardless of prognosis."

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