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Background: Reports of poor outcomes among older adults with COVID-19 may have changed patient perceptions of Do-Not-Resuscitate (DNR) orders or caused providers to pressure older adults into accepting DNR orders to conserve resources. Objective: We determined early-DNR utilization during COVID-19 surges compared with nonsurge periods among nonsurgical adults ≥75 and its connection to hospital mortality. Methods: We conducted a retrospective cohort study among adults ≥75 years using the California Patient Discharge Database 2020. The primary outcome was early-DNR utilization. Control cohorts included nonsurgical adults <75 years in 2020 and nonsurgical adults ≥75 in 2019. Multiple causal inference methods were used to address measured and unmeasured confounding. Results: A total of 487,955 adults ≥75 years were identified, with 233,678 admitted during COVID-19 surges. Older adults admitted during surges had higher rates of early-DNR orders (30.1% vs. 29.4%, absolute risk differences = 0.7, 95% confidence interval [CI]: 0.5–1.0) even after adjusting for patient case-mix (adjusted odds ratio [aOR] = 1.02, 95% CI: 1.01–1.04). Patients with early-DNR orders experienced higher hospital mortality (15.5% vs. 4.8%, aOR = 3.96, 95% CI: 3.85–4.06). Difference-in-difference analyses demonstrated that adults <75 years in 2020 and adults ≥75 years in 2019 did not experience variation in early-DNR utilization. Conclusions: Older adults had slightly higher rates of early-DNR orders during COVID-19 surges compared with nonsurge periods. While the difference in early-DNR utilization was small, it was linked to higher odds of death. The increase in early-DNR use only during COVID-19 surges and only among older adults may reflect changes in patient preferences or increased pressure on older adults stemming from provider fears of rationing during COVID-19 surges. [ABSTRACT FROM AUTHOR]

• Results from this study suggest that the 2016 ACA payment rules for ACP were associated with greater DNR participation overall, but did not specifically increase DNR participation more for racial and ethnic minorities. • Additionally, the results suggest that the ACA payment rules were associated with lower improvements in DNR participation for all race and ethnic groups except for white non-Hispanic patients. • Although the ACA increased healthcare coverage among racial and ethnic minority groups, and the reimbursement policy incentivized health care providers to initiate ACP conversations, racial and ethnic disparities in utilization of DNR orders did not improve over the time period investigated in CA. The Affordable Care Act (ACA) created new payment rules that provided reimbursement for physicians to engage in advance care planning (ACP) conversations with patients. This reimbursement policy has the potential to increase ACP participation, including among racial and ethnic minority groups that have had lower ACP participation. To examine whether the ACP payment rules were associated with an increase in use of do-not-resuscitate (DNR) orders, particularly among racial and ethnic minority groups, among patients diagnosed with heart failure (HF) in California. The California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data Set was used to identify a cohort of elderly patients with a principal diagnosis of HF. This study included 432,520 hospital admissions of patients over the age of 65 with a primary diagnosis of HF between 2012 and 2018. DNR status was identified using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision, codes. There was a small increase in the utilization of DNR orders overall after the ACA reimbursement policy, but the change was not significantly different for all racial and ethnic groups when compared to white non-Hispanic patients. ACP payment rules provided in the ACA were associated with increased utilization of DNR, but the effect was not significantly different for racial and ethnic minorities hospitalized with HF in CA. Additional efforts are needed to increase ACP participation among racial and ethnic minorities. [ABSTRACT FROM AUTHOR]

In modern medicine and technologies, it is commonly accepted and recognized by the laws in western countries that patients have decision-making rights regarding the end of their lives. While people can choose medical cardiopulmonary resuscitation (CPR), some may refuse it for personal, moral, social, or religious reasons. Sometimes, when treatment is futile, it is possible to make an end-of-life decision with a recommendation from a doctor. Therefore, issues that must be addressed in both ethical and Islamic terms surround end-of-life decisions. One of these issues involves Do-Not- Resuscitate (DNR) orders. DNR is a decision that means treatment methods are not applied to a patient when their breathing or heart has stopped for some reason. This decision is taken either because of a testament signed by the person when they were healthy or because the doctor cannot perform any curative intervention. In this study, the status and applicability of DNR orders will be investigated from an Islamic Bioethics perspective, and fatwas will be cited to clarify the status of DNR orders in Islam. Additionally, because DNR is essentially the refusal or withholding of medical treatment, the provisions of Islam concerning seeking medical treatment and withholding treatment have been extensively researched. This study aims to demonstrate that DNR instructions are Islamically applicable in cases where treatment is unnecessary, considering classical and contemporary Islamic sources. [ABSTRACT FROM AUTHOR]