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BACKGROUND Patients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission. METHODS This single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis. RESULTS A total of 72 patients were included in this study, of which 68.1% died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p

Purpose Studies concerning do-not-resuscitate (DNR) orders in mainland China are rather scarce. We explored the prevalence and related factors of DNR orders among in-hospital cardiac arrest (IHCA) patients at a general tertiary hospital in mainland China. Materials and Methods We identified all IHCA patients hospital-wide between July 2019 and September 2020. Data regarding DNR status were collected from medical records. We investigated the frequency of DNR orders and explored the determinant factors of DNR establishment using logistic regression. Results A total of 1154 IHCA patients were included, 535 (46.4%) of whom established DNR orders. The following variables were independently associated with a higher DNR rate: female (OR 1.491; 95% CI 1.130–1.965), older age (OR 1.016; 95% CI 1.008–1.024), being a local resident (OR 1.790; 95% CI 1.344–2.383), pulmonary infection (OR 1.398; 95% CI 1052–1.859), respiratory insufficiency (OR 1.356; 95% CI 1.009–1.823), shock (OR 1.735; 95% CI 1.301–2.313), acute stroke (OR 1.821; 95% CI 1.235–2.686),neurological dysfunction (OR 1.527; 95% CI 1.149–2.028) and cancer (OR 3.316; 95% CI 2.461–4.468). Counterintuitively, patients with new-onset coronary artery disease (OR 0.592; 95% CI 0.419–0.837) were less likely to create DNR orders. Conclusion In mainland China, the DNR order signing rate is low, and the establishment of a DNR order is associated with demographics and comorbidity characteristics.

End-tidal carbon dioxide (ETCO2) has been suggested to have prognostic implications during out-of-hospital cardiac arrest (OHCA). Our objective was to determine if the change in ETCO2 (delta ETCO2) during resuscitation was predictive of future return of spontaneous circulation (ROSC) in patients with pulseless electrical activity (PEA) arrests.We performed a retrospective, observational study of adult (≥18 years of age) non-traumatic PEA OHCAs in two Canadian EMS systems over a two-year time frame beginning on January 1, 2018. Cases were excluded if there was a Do Not Resuscitate order (DNR), had no advanced airway, or had less than two ETCO2 recordings. We performed multivariable logistic regression to examine the association between ETCO2 measures and ROSC. Second, we examined the prognostic performance (sensitivity, specificity, NPV, PPV) for ETCO2 at specific thresholds for predicting ROSC.A total of 208 OHCA met inclusion criteria of which 67 (32%) obtained ROSC. After adjusting for pre-determined confounders, there was an association between delta ETCO2 and ROSC (odds ratio [OR] per 10 mmHg increase in ETCO2 of 1.74 (95% confidence interval [CI] 1.35 to 2.24); P value 0.001). We also found significant associations between both initial ETCO2 and final ETCO2 with ROSC.Our analysis indicates that there is a positive linear relationship between delta ETCO2 and ROSC with values of delta ETCO2 20 mmHg being highly specific for ROSC in PEA patients. As such, patients with up-trending ETCO2 values should have resuscitation continued unless there is overwhelming clinical evidence to the contrary.

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, “full code” is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.

Introduction: Knowledge regarding and attitude towards end-of-life care can shape the behaviour and actions of a health professional in provision of supportive care for the comfort of the patients as well as their family members. Very little is known about nurses’ knowledge and attitude regarding do-not-resuscitate (DNR) order. Therefore, the purpose of this study was to identify the knowledge of and attitude towards DNR order and relationship between knowledge and attitude towards DNR order among the nurses of a tertiary level hospital. Methods: Descriptive correlation design was used. Convenient sampling method was used to select 70 nurses from a tertiary level hospital. Data were collected using pretested self administered structured questionnaire. Data were analysed using SPSS version 20 and analysed using descriptive and inferential statistics. Result: Among 70 respondents, almost all (95.7%) of the respondents had good level of knowledge, 2.9% had fair and 1.4% had poor level of knowledge. Most (80.0%) of the respondents had positive attitude towards DNR order and 20.0% had negative attitude. There was a positive relationship between knowledge of and attitude towards DNR order (r = 0.068) but the relationship was statistically insignificant. Conclusions: Based on the findings, the study concludes that nurses of tertiary level hospital have good knowledge and positive attitude towards DNR order. Likewise, knowledge regarding DNR order is related with the attitude towards DNR order and thus knowledge can be enhanced to improve the attitude towards DNR by regular in-service education.

Introduction NICE guideline recommends that all patients with Parkinson’s disease should be reviewed every 6–12 months and offered opportunities to discuss Advanced Care Planning (ACP) (1, 2). There is evidence demonstrating that Advanced Care Plans results in shorter length of stay in the last year of life and lower hospital costs (2, 3). A local baseline audit showed that Advanced Care Planning was not performed adequately. Methods A local baseline audit on community care home patients with Parkinsonism was completed in February 2018. A community-based Parkinson’s clinic was commenced in June 2018. Patients with parkinsonism who were unable to attend hospital clinics due to underlying frailty, neuropsychiatry and physical issues, were reviewed. At each visit, advice was provided on medicines management and there were discussions around Advance Care Planning. A re-audit was completed in August 2019. Patient’s Electronic Patient Records were scrutinised to evaluate progress and identify those who had died. Data was analysed using Microsoft Excel. Results The initiative contributed directly to end of life care in 7/17 patients. Parkinson’s disease medications were rationalised in 11/17 (64.70%). 14/17 (82.35%) had a community-based Do Not Resuscitate order completed. Conclusions The community Parkinson’s clinic service promoted Advance Care Planning in patients with Parkinsonism. This service provides specialist input in frail older people with Parkinsonism who were unable to attend hospital clinic, promoting end of life choices around where they wished to die and avoiding unnecessary hospitalisation in the final stages of their life.

Objectives: Care for older adults with cancer became more challenging during the COVID-19 pandemic. We sought to examine cancer care providers' attitudes toward the barriers and facilitators related to the care for these patients during the pandemic. Materials and Methods: Members of the Advocacy Committee of the Cancer and Aging Research Group, along with the Association of Community Cancer Centers, developed the survey distributed to multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Participants were recruited by email sent through four professional organizations' listservs, email blasts, and messages through social media. Results: Complete data was available from 274 respondents. Only 15.4% had access to written guidelines that specifically address the management of older adults with cancer during the COVID-19 pandemic. Age was ranked fifth as the reason for postponing treatment following comorbid conditions, cancer stage, frailty, and performance status. Barriers to the transition to telehealth were found at the patient-, healthcare worker-, and institutional-levels. Providers reported increased barriers in accessing basic needs among older adults with cancer. Most respondents agreed (86.3%) that decision making about Do Not Resuscitate orders should be the result of discussion with the patient and the healthcare proxy in all situations. The top five concerns reported were related to patient safety, treatment delays, healthcare worker mental health and burnout, and personal safety for family and self. Conclusion: These findings demand resources and support allocation for older adults with cancer and healthcare providers during the COVID-19 pandemic.

Background Nurses and Doctor of Pharmacy (pharmD) must communicate and properly documented the do not resuscitate orders for terminally ill children and their relatives. They also have to offer excellent care including more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary cardiopulmonary resuscitation. This research was aimed to survey attitudes of nursing and pharmD undergraduate students about the "do not resuscitate" order for children with terminally ill diseases. Methods A cross-sectional correlational design was used to study the correlation between attitude toward DNR and demographic variables. More than 400 nursing and pharmD students from Jordan University of Science and Technology were recruited in this study. All the participating students were e-mailed information regarding the study, including the web survey link. Results The results showed that there was a significant difference in perception toward do not resuscitate order between nursing and pharmD students (p ≤ 0.05). The pharmD students had more positive attitude toward do not resuscitate than the nursing students. Approximately, 60% of the nursing and pharmD students would disclose the need for the do not resuscitate order for children with terminally ill diseases Demographic variables were not associated with the perception toward do not resuscitate orders (p ≥ 0.05). Conclusion This study showed that Jordanian nursing and pharmD students are willing to learn more about different aspects of do not resuscitate orders for terminally ill children. Analyzing their responses to many items showed their misconception about do not resuscitate orders for terminally ill children.

Background: There are some restrictions in Japan regarding end-of-life care. For example, only physicians can legally issue death certificates. By law, ambulance staff members perform cardiopulmonary resuscitation (CPR) for all patients with cardiopulmonary arrest (CPA). Therefore, it is difficult to transport patients to hospitals without CPR, even in cases of terminal patients with do-not-attempt-resuscitation (DNAR) order. Furthermore, there is no 24-hour home care nursing system in our area. Therefore, terminal patients are unable to spend their last moments at their home in the Kuji area. Objective: To design a system in which terminal patients who wish to spend their final moments at their home can be transported to the hospital without CPR after at-home CPA and a system to avoid confusion between ambulance staff and family members using instructions provided by the physician. Setting/Subjects: The subjects were terminal patients with DNAR order who wanted to stay at home. The instruction to not perform CPR after CPA was created as a document by physicians. Patient information was shared with the fire department; patients were transported to our hospital without CPR after at-home CPA. Results: In total, 26 patients died during the study period; eight received emergency transport to the hospital without CPR after CPA. CPR was not performed for any patient. Conclusion: A system transporting terminal patients without CPR after CPA was necessary in our area. This instruction allows terminal patients to spend their last moments where they wish and avoids unwanted CPR and troubles after CPA.

Background: Very few studies have investigated the racial differences in do-not-resuscitate (DNR) orders in children, and these studies are limited to oncological cases. We aim to characterize the ...

Prior work has shown substantial between-hospital variation in do-not-resuscitate orders, but stability of do-not-resuscitate preferences between hospitalizations and the institutional influence on do-not-resuscitate reversals are unclear. We determined the extent of do-not-resuscitate reversals between hospitalizations and the association of the readmission hospital with do-not-resuscitate reversal.Retrospective cohort study.California Patient Discharge Database, 2016-2018.Nonsurgical patients admitted to an acute care hospital with an early do-not-resuscitate order (within 24 hr of admission).None.We identified nonsurgical adult patients who survived an initial hospitalization with an early-do-not-resuscitate order and were readmitted within 30 days. The primary outcome was the association of do-not-resuscitate reversal with readmission to the same or different hospital from the initial hospital. Secondary outcomes included association of readmission to a low versus high do-not-resuscitate-rate hospital with do-not-resuscitate reversal. Among 49,336 patients readmitted within 30 days following a first do-not-resuscitate hospitalization, 22,251 (45.1%) experienced do-not-resuscitate reversal upon readmission. Patients readmitted to a different hospital versus the same hospital were at higher risk of do-not-resuscitate reversal (59.5% vs 38.5%; p0.001; adjusted odds ratio = 2.4; 95% CI, 2.3-2.5). Patients readmitted to low versus high do-not-resuscitate-rate hospitals were more likely to have do-not-resuscitate reversals (do-not-resuscitate-rate quartile 1 77.0% vs quartile 4 27.2%; p0.001; adjusted odds ratio = 11.9; 95% CI, 10.7-13.2). When readmitted to a different versus the same hospital, patients with do-not-resuscitate reversal had higher rates of mechanical ventilation (adjusted odds ratio = 1.9; 95% CI, 1.6-2.1) and hospital death (adjusted odds ratio = 1.2; 95% CI, 1.1-1.3).Do-not-resuscitate reversals at the time of readmission are more common than previously reported. Although changes in patient preferences may partially explain between-hospital differences, we observed a strong hospital effect contributing to high do-not-resuscitate-reversal rates with significant implications for patient outcomes and resource.

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 figures, 8 tables, and 58 references Keywords: Advance directives, power of attorney in health care, do not resuscitate order, decision-making, end-of-life, critical care

The aim of this study was to determine nurses’ opinions on Do Not Resuscitate (DNR) orders. This is a descriptive study. A total of 1250 nurses participated in this study. The mean age of participants was 34.5 ± 7.7 years; 92.6% were women; 56.4% had bachelor’s degrees, and 28.8% were intensive care, oncology, or palliative care nurses. Most participants (94.3%) agreed that healthcare professionals involved in DNR decision-making processes should have ethical competence, while they were mostly undecided (43%) about the statement whether or not DNR should be legal. More than half the participants (60.2%) disagreed with the idea that DNR implementation causes an ethical dilemma. Participants’ opinions on DNR decisions significantly differed according to the number of years of employment and unit of duty. The results showed that most of the nurses had positive attitudes towards DNR orders despite it being illegal. Future studies are needed to better understand family members’ and decision makers’ perceptions of DNR orders for patients.

Background The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives. Aim To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding. Methods This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire. Results A total of 1136 patients completed the questionnaire. Patients’ CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically. Conclusions The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

A Do Not Resuscitate (DNR) order should only impede the performance of cardiopulmonary resuscitation in case of cardiac or respiratory arrest; it should not interfere with any other treatment decisions.To study the impact of DNR order placement on daily clinical care of patients.This was a retrospective cohort study of 72 patients in a tertiary care centre in Saudi Arabia. Daily clinical care measures were collected for 2 weeks prior and 2 weeks after DNR order placement and included vital signs, nursing care, comfort measures, documentation, visits by senior and junior physicians, and tests completed.Malignancy was the most common diagnostic category (43.1%). There was a significant reduction in vital signs documentation, tests completed, documentation, and visits by physicians after DNR orders, with no change in nursing care and comfort measures. No differences were seen for place of DNR order (intensive care unit vs medical ward), category of disease, or sex, but there were differences for documentation (more in females) and vital signs (more in males). More vital signs were documented and more tests were done in patients who survived compared to those who died. Regression analysis showed that the frequency of post-DNR order vital signs measurements and investigations done was not related to sex, age, diagnosis, time from admission to DNR order, or location of patients. Time to death was only related to sex and post-DNR order summary documentation.Placement of DNR orders significantly reduced vital signs measurements, investigations done, documentation and visits by physicians but not nursing care and comfort measures.تردد المرضى في قبول أمر "عدم الإنعاش": الآثار المترتبة على الرعاية السريرية.أمل الفرحان، منال الحارثي، منيرة بن موسى، عفاف مُقدم، حمدان جحدلي ، جنان شامو، عبد الله السياري، سليم باهارون.يجب أن يمنع أمر "عدم الإنعاش" أداءَ الإنعاش القلبي الرئوي فقط في حالة تَوَقُّف القَلْب أو التنفس؛ ولا يجب أن يتداخل مع أي قرارات أخرى للعلاج.دراسة أثر تنفيذ أمر "عدم الإنعاش" على الرعاية السريرية اليومية للمرضى.أُجريت دراسة أترابية استرجاعية شملت 72 مريضاً في أحد مراكز الرعاية الثالثية في المملكة العربية السعودية. وقد حُصرت تدابير الرعاية السريرية اليومية لمدة أسبوعين قبل أمر "عدم الإنعاش" وأسبوعين آخرين بعده، وشملت العلامات الحيوية، والرعاية التمريضية، وتدابير تحقيق الراحة، والتوثيق، وزيارات كبار وشباب الأطباء، وإتمام الفحوص.كان التشخيص بالإصابة بورم خبيث أكثر الفئات التشخيصية الشائعة (43.1٪). وقد حدث انخفاض ملحوظ في توثيق العلامات الحيوية، وإتمام الفحوص، والتوثيق، وزيارات الأطباء عقب إصدار أوامر "عدم الإنعاش"، مع عدم وجود أي تغيير في الرعاية التمريضية وتدابير تحقيق الراحة. ولم يُلاحَظ أي تغيير في تنفيذ أمر "عدم الإنعاش" (وحدة الرعاية المركزة مقابل الجناح الطبي)، أو فئة المرض، أو نوع الجنس، ولكن لوحظ بعض التباين من حيث التوثيق (أكثر في الإناث) والعلامات الحيوية (أكثر في الذكور). وكان معدل توثيق العلامات الحيوية وإجراء مزيد من الفحوص أعلى في المرضى الذين نجوا وظلوا على قيد الحياة عنه في الذين تُوفُّوا. وقد بيّ تحليل الانحدار أن وتيرة أخذ قياسات العلامات الحيوية والاستقصاءات عقب أمر "عدم الإنعاش" غير مرتبطة بنوع الجنس، أو العمر، أو التشخيص، أو المدة الزمنية من وقت دخول المستشفى وحتى صدور الأمر، أو مكان المرضى. وارتبطت الفترة الزمنية حتى الوفاة فقط بنوع الجنس وتوثيق ملخص ما بعد أمر "عدم الإنعاش".أدى تنفيذ أمر "عدم الإنعاش" بصورة كبيرة إلى خفض قياسات العلامات الحيوية، وإتمام الاستقصاءات، والتوثيق، وزيارات الأطباء، ولكن الأمر كان مختلفاً بالنسبة للرعاية التمريضية وتدابير تحقيق الراحة.Réticence du patient à accepter l’ordre de ne pas réanimer : conséquences sur les soins cliniques.Un ordre de ne pas réanimer doit seulement empêcher l’exécution de la réanimation cardio-respiratoire en cas d’arrêt cardiaque ou respiratoire ; il ne doit pas interférer avec d’autres décisions thérapeutiques.Étudier les conséquences de l’ordre de ne pas réanimer sur les soins cliniques quotidiens des patients.Il s’agissait d’une étude de cohorte rétrospective portant sur 72 patients d’un centre de soins tertiaires en Arabie saoudite. Des mesures des soins cliniques quotidiens ont été recueillies pendant deux semaines avant et deux semaines suite à l’émission de l’ordre de ne pas réanimer. Elles ont notamment pris en considération les signes vitaux, les soins infirmiers, les mesures de confort, la documentation, les visites des médecins principaux ou assistants et les examens effectués.La malignité était la catégorie de diagnostic la plus courante (43,1 %). On a constaté une réduction significative des mesures des signes vitaux, des examens effectués, de la documentation et des visites des médecins suite à l’émission des ordres de ne pas réanimer, sans aucun changement au niveau des soins infirmiers et des mesures de confort. Aucune différence n’a été constatée en ce qui concerne le lieu associé à l’ordre de ne pas réanimer (unité de soins intensifs ou service d’hospitalisation), la catégorie de la maladie ou le sexe, mais des différences ont été observées pour la documentation (plus détaillée chez les femmes) et la mesure des signes vitaux (plus fréquente chez les hommes). Les signes vitaux avaient davantage été documentés et plus d’examens avaient été effectués chez les patients qui ont survécu que chez ceux qui sont décédés. L’analyse de régression a montré que la fréquence de la mesure des signes vitaux et des examens effectués suite à l’émission de l’ordre de ne pas réanimer n’était pas liée au sexe, à l’âge, au diagnostic, au temps écoulé entre l’admission et l’émission de l’ordre de ne pas réanimer, ni au lieu de prise en charge du patient. Le délai avant le décès n’était lié qu’au sexe et à la documentation sommaire établie à la suite de l’émission de l’ordre.L’émission d’un ordre de ne pas réanimer réduisait de manière significative la mesure des signes vitaux, les examens effectués, la documentation et les visites des médecins, mais pas les soins infirmiers ni lesmesures de confort.

Advance directives are documents to convey patients’ preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient‐centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life‐Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.

Purpose: The objective of this study is to describe characteristics and short- and long-term outcomes of patients with hematologic malignancies who received cardiopulmonary resuscitation (CPR). Methods: A retrospective review was conducted of all Code Blues at a large comprehensive cancer center. Demographic, clinical, and outcome variables were analyzed for patients with a hematologic malignancy who underwent CPR. Results: Of 258 patients, 60.1% had leukemia. Outcomes included return of spontaneous circulation (70.2%), hospital survival (12%), and 90-day, 6-month, and 1-year survival rates of 9.8%, 8.2%, and 5.9%, respectively. Factors associated with hospital mortality included establishing a do not resuscitate order after CPR (p < .0001), location of CPR (p = .0004), cause of arrest (p = .0019), requiring vasopressors (p = .0130), mechanical ventilation (p = .0423), and acute renal failure post CPR (p = .0006). Although no difference in hospital survival between leukemia and non-leukemia patients was found, more non-leukemia patients were alive at 90 days (p = .0099), 6 months (p = .0023), and 1 year (p = .0119). Conclusions: Factors including organ dysfunction, location of CPR, and cause of arrest are associated with hospital mortality post CPR. However, immediate survival post CPR does not seem to be affected by a diagnosis of leukemia. These data should assist health care providers with discussions regarding advance care planning and goals of care after cardiac arrest.

Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end‐of‐life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end‐of‐life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision‐making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7‐minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.

Context The premise of advance directives and care planning is to help people articulate and document their wishes so surrogate decision-makers and providers can honor them. However, beyond the completion of such a document, underlying challenges are often unaddressed Objectives The overall purpose of the study was to investigate how communication, including but not limited to the completion of advance directives, and caregiving influenced family caregivers’ experiences. Communication gaps and caregiving challenges that were unaddressed by advance directives are presented. Methods Non-dominant simultaneous mixed-methods (QUAL-QUAN) were used to explore how end-of-life events influenced family caregivers. In-depth interviews were conducted with 108 caregivers about 4 months following the death of a family member who was in hospice care. Results A majority (n=90; 84.9%) had specific wishes about end-of-life treatment. Patients had a completed: Health Care Proxy-101 (93.3%); Living Will–43 (39.8%); Do Not Resuscitate orders (DNR)–82 (75.9%) and Medical Orders for Life Sustaining Treatment–40 (37%). A majority (n=83; 76.9%) of caregivers said that they had “enough” or “just the right amount” of information to prepare for the patients’ death. Five themes illustrated caregivers’ experiences: Family Conflict; Patient/Family-Provider Conflict; Uncertainty, Caregiving Realities; Awareness-Avoidance of Dying. Conclusion A majority of had an advance directive, yet caregivers expressed feeling unprepared for decision-making, caregiving and discussing it with the dying person. The advance directive and care planning process fell short of providing needed communication, knowledge and preparation; it can be an opportunity for teaching, learning, preparing and supporting families at life's end.

BACKGROUND: Despite having high comorbidity rates and shortened life expectancy, patients with ESKD may harbor unrealistically optimistic expectations about their prognoses. Whether this affects resuscitation orders is unknown. METHODS: To determine whether do-not-resuscitate (DNR) orders differ among patients with ESKD compared with other critically ill patients, including those with diseases of other major organs, we investigated DNR orders on admission to intensive care units (ICUs) among 106,873 patients in the United States. RESULTS: Major organ disease uniformly associated with increased risk of hospital mortality, particularly for cirrhosis (adjusted odds ratio [aOR], 2.67; 95% confidence interval [95% CI], 2.30 to 3.08), and ESKD (aOR, 1.47; 95% CI, 1.31 to 1.65). Compared with critically ill patients without major organ disease, patients with stroke, cancer, heart failure, dementia, chronic obstructive pulmonary disease, and cirrhosis were statistically more likely to have a DNR order on ICU admission; those with ESKD were not. Findings were similar when comparing patients with a single organ disease with those without organ disease. The disconnect between prognosis and DNR use was most notable among Black patients, for whom ESKD (compared with no major organ disease) was associated with a 62% (aOR, 1.62; 95% CI, 1.27 to 2.04) higher odds of hospital mortality, but no appreciable difference in DNR utilization (aOR, 1.06; 95% CI, 0.66 to 1.62). CONCLUSIONS: Unlike patients with diseases of other major organs, critically ill patients with ESKD were not more likely to have a DNR order than patients without ESKD. Whether this reflects a greater lack of advance care planning in the nephrology community, as well as a missed opportunity to minimize potentially needless patient suffering, requires further study.

These authors share thoughts about discriminatory approaches to the allocation of resources during health care catastrophes, such as the COVID-19 pandemic. They argue that, although prioritization of resources is critical, fairness requires giving each patient his or her due based on clinical criteria applied to the individual rather than assumptions that favor or disfavor groups.

Background and objectives High-flow nasal cannula (HFNC) oxygen may provide tailored benefits in patients with preset treatment limitations. The objective of this study was to assess the effectiveness of HFNC oxygen in patients with do-not-intubate (DNI) and/or do-not-resuscitate (DNR) orders. Methods We conducted a systematic review of interventional and observational studies. A search was performed using MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science, from inception to October 15, 2018. Results We included six studies evaluating 293 patients. All studies had a high risk of bias. The hospital mortality rates of patients with DNI and/or DNR orders receiving HFNC oxygen were variable and ranged from 40% to 87%. In two before and after studies, the initiation of HFNC oxygen was associated with improved oxygenation and reduced respiratory rates. One comparative study found no difference in dyspnea reduction or morphine doses between patients using HFNC oxygen versus conventional oxygen. No studies evaluated quality of life in survivors or quality of death in nonsurvivors. HFNC was generally well tolerated with few adverse events identified. Conclusions While HFNC oxygen remains a viable treatment option for hospitalized patients who have acute respiratory failure and a DNI and/or DNR order, there is a paucity of high-quality, comparative, effectiveness data to guide the usage of HFNC oxygen compared with other treatments, such as noninvasive ventilation, conventional oxygen, and palliative opioids.

Background Communication skills may be an important skill for the front-line emergency physicians. Aim This study aimed to investigate the effect of training in a SHARE communication course by emergency physicians on patient notification and signing of do-not-resuscitate (DNR) orders for critical patients in the emergency room. Design From a total of 29 attending physicians in the emergency department, 19 physicians had been trained in the SHARE communication course. An observation form designed based on the SHARE training was completed by two observers who noted the communication process between physicians and patients and family members during patient notification and signing a DNR order. To assess the influence of physicians trained in a SHARE communication course on the signing of DNR orders, a propensity score-matched population was created to reduce the potential selection bias of patients and family members. Setting Level 1 trauma medical center in southern Taiwan. Results There were 145 individuals enrolled in the study, of which 93 signed the DNR order, and 52 did not sign it. Analysis from 23 matched pairs from this population revealed that significantly more family members would sign a DNR order if the physician had been trained in the SHARE communication course than when they did not receive this training (78.3% vs. 39.1%, respectively, p = 0.017). The overall score of the observation form for physicians was higher in those individuals who had signed a DNR order than in those who did not sign it (29.48 ± 3.72 vs. 26.13 ± 3.52, respectively, p = 0.003), especially when the physician had chosen a quiet environment (1.35 ± 0.65 vs. 0.87 ± 0.69, respectively, p = 0.020), understood the patient's wishes and confirmed them (1.78 ± 0.42 vs. 1.30 ± 0.70, respectively, p = 0.008), and expressed concern (1.48 ± 0.79 vs. 0.96 ± 0.77, respectively, p = 0.028). In addition, a feedback survey about the feelings experienced by these physicians during the process of patient notification did not reveal a significant difference during the communication with those who had or had not signed DNR orders. Conclusion The training in a SHARE communication course can improve the communication skills of emergency physicians in patient notification and signing of DNR orders for critical patients.

Context Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited. Objectives To evaluate perioperative management of DNR orders at a tertiary care children's hospital. Methods We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period. Results Twenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point. Conclusion Opportunities exist to improve how DNR orders are managed during the perioperative period.

Background: In the last years, the structure of Pediatric Palliative Care in Germany has developed more and more. Since 2007, there is a legal claim for a specialized palliative care in German which also applies to children. Therefore, the need of an advance care planning for children is frequently discussed. In Germany, a written advance is judicially approved only when the person concerned is of full age, intentions to change this legal ground are going on. Nevertheless in many institutions involved in pediatric palliative care standard forms similar to an advance patient directive are used, especially since 2009 when a Do-Not-Resuscitate-Order (DNR-Order) equivalent for children was published on which many German pediatric medical societies had agreed. Methods: To get an overview which DNR-Order equivalents are actually used in pediatric palliative care in Germany we sent a questionnaire with 10 items to 174 institutions that are involved in pediatric oncological palliative care between August 2012 and October 2013. Results: Only 46.9% of replying institutions used the DNR-Order equivalent for children approved by many German pediatric societies. When asked for optimizing such an advance patient directive for minors it was mostly suggested to include always a protocol of the consenting talk, an individualized treatment algorithm of all therapeutic options (not only emergency measures) in the palliative setting, and a more detailed information about the patient’s current palliative situation. Conclusions: All collected data were summarized within a suggestion for a new advance pediatric oncological care planning standard form for minors in Germany.

PURPOSE Issues related to life and death are largely influenced by the culture and religious beliefs of a society. This research aimed to survey a sample of oncology nurses in Saudi Arabia about their attitude towards the do not resuscitate order (DNR). METHOD A cross-sectional design was employed. A survey was sent to 190 nurses in the Comprehensive Cancer Center (CCC) in King Fahad Medical City (KFMC). A total of 157 nurses with a diploma or higher degree agreed to participate in the study. RESULTS Many nurses showed a neutral attitude regarding DNR to cancer patients and/or their families 2.4 ± 0.4. Moreover, the results of the multiple logistic regression tests revealed that all the listed factors are not associated with the attitude towards DNR orders (P > .05). CONCLUSION It is generally believed that nurses the faith and background of nurses from Muslim countries has a profound influence on their attitude towards DNR. However, this was not the picture that was revealed by the results of this study. In this study, all the nurses made it clear that they wanted to know about the autonomy of patients in respect of DNR orders. IMPLICATION TO CLINICAL PRACTICE It is necessary to develop programmes that address the DNR order and respect patient autonomy and rights. Moreover, hospital policies that address the issues of DNR order are required for all end-of-life care.

BACKGROUND The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders. METHODS This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR. RESULTS A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018). CONCLUSION The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.

BackgroundDo-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists.MethodsWe performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model.ResultsA total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant.ConclusionsThe use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

Background & Objective: Understanding the demographics of mortality and its burden in the emergency department of a tertiary care setup can lead to better planning and allocation of resources to streamline process flow. This can be achieved systematically through mortality audit that can identify the loopholes and areas of improvement. Our objective was to characterize the epidemiology of ED mortality in a tertiary care hospital of Karachi, Pakistan. Methods: A five-year retrospective chart review of 322 adult mortalities presenting between January l, 2014 – December 31, 2018 was conducted in the emergency department (ED) of The Indus Hospital (TIH), Karachi. All expiries in ED were included while those brought dead and with do not resuscitate order (DNAR) were excluded. Results: Mortality incidence of 0.076% (7.6/10,000 ED visits in five years) was reported. Amongst 507,759 adult ED visits, 322 mortalities were documented. Mean time lapse before presentation was 44±147 hours and mean length of stay before death was 3.4±2.8 hours. Acute coronary syndrome (ACS) was the predominant cause of death with 109 (33.8%) expiries. Significant association was reported between no history of prior care and high priority (P1) cases (p=0.013). Conclusions: This study identified the contributing factors to adverse outcome such as delayed presentation with systemic gaps in management and unknown disposition. The need to improve these factors at local and national level can lead to improvement in Pakistani healthcare sector. doi: https://doi.org/10.12669/pjms.37.3.3680 How to cite this:Mukhtar S, Saleem SG, Ali S, Khatri SA, Yaffee AQ. Standing at the edge of mortality; Five-year audit of an emergency department of a tertiary care hospital in a low resource setup. Pak J Med Sci. 2021;37(3):633-638. doi: https://doi.org/10.12669/pjms.37.3.3680 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

BACKGROUND Similar to the significant rise in the geriatric population in the United States, trauma centers have seen an increase in geriatric trauma patients. These patients present with additional challenges such as a higher likelihood of undertriage, mortality, and frailty. In addition, the varying presence of advanced directive documentation increases the importance of early palliative care consultations for geriatric trauma patients. OBJECTIVE In 2018, a Level I trauma center in the Midwest reviewed the American College of Surgeons Trauma Quality Improvement Program's Palliative Care Best Practice Guideline to identify opportunities for improvement to strengthen the collaboration between the palliative care consult service and trauma program. METHODS The guideline drove improvements, which included documentation changes (i.e., expansion of palliative care consultation triggers, frailty assessment, advanced directives questions, depression screening, and addition of palliative care consultation section on the performance improvement program form) and training (1-hr lecture on palliative care and 5-hr palliative care simulation training) opportunities. RESULTS A 3-month manual chart review (March 2019 through May 2019) revealed that by May 2019, 87.2% of admitted geriatric trauma patients received frailty assessments, which surpassed the benchmark (≥85%). In addition, advanced care planning questions (i.e., health care power of attorney, do not resuscitate order, or living will) exceeded the benchmarks set forth by the guideline (≥90%), with all of the questions being asked and documented in 95.7% of those same patient charts by May 2019. CONCLUSION This quality improvement project has applicability for trauma centers that treat geriatric trauma patients; using the guidelines can drive changes to meet individual institution needs.

Objective Current guidelines recommend deferring prognostic decisions for at least 72 h following admission after Out of Hospital cardiac arrest (OHCA). Most non-survivors experience withdrawal of life sustaining therapy (WLST), and early WLST may adversely impact survival. We sought to characterize the hospital length of stay (LOS) and timing of Do Not Resuscitate (DNR) orders (as surrogates for WLST), to assess their relationship to survival following cardiac arrest. Design We performed a retrospective cohort study of probabilistically linked cardiac arrest registries (Cardiac Arrest Registry to Enhance Survival (CARES) and Michigan Inpatient Database (MIDB) from 2014 to 2017. Patients Adult (≥18 years) patients admitted following OHCA were included. We considered LOS ≤ 3 days (short LOS) and written DNR order with LOS ≤ 3 days (Early DNR) as indicators of early WLST. Our primary outcome was survival to hospital discharge. We utilized multilevel logistic regression clustered by hospital to examine associations of these variables, patient characteristics and survival to hospital discharge. Measurement and Main Results We included 3644 patients from 38 hospitals with >30 patients. Patients mean age was 62.4 years and were predominately male (59.3%). LOS ≤ 3 days (ORadj = 0.11) and early DNR (ORadj = 0.02) were inversely associated with survival to discharge. There was a non-significant inverse association between hospital rates of LOS ≤ 3 days and survival (p = 0.11), and Early DNR and survival (p = 0.83). In the multilevel model, using median odd ratios to assess variation in LOS ≤ 3 days and survival, patient characteristics contributed more to variability in surviival than between-hospital variation. However, between-hospital variation contributed more to variability than patient characteristics in the provision of early DNR orders. Conclusions We observed that LOS ≤ 3 days for post-arrest patients was negatively-associated with survival, with both patient characteristics and between-hospital variation associated with outcomes. However, between-hospital variation appears to be more highly-associated with provision of early DNR orders than patient characteristics. Further work is needed to assess variation in early DNR orders and their impact on patient survival.

Introduction/background: Do not resuscitate (DNR) orders have been associated with higher mortality in hospitalized patients which the question if they these patients are victims of the self-fulfilling prophecy; that the odds of their survival is made worse by withholding aggressive treatment. In addition, previous reports show that racial and ethnic minorities tend to opt for more aggressive and lifesaving procedures as compared to Whites. Methods: We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all intracerebral hemorrhage (ICH) patients. DNR code status was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, length of stay) were compared between the two groups. DNR code status was compared between different racial groups. Results: Of the 884379 patients with ICH, 81968 (9.26%%) had DNR order. ICH patients with DNR order had higher proportion of females (55.1% versus 49.1%, P Conclusions: While there may be other explanations at play, the higher mortality and shorter LOS suggest that early DNR orders do lead to the self-fulfilling prophecy. The lower proportion of DNR orders among minorities suggest a sociocultural aspect in accepting the concept of DNR. These two facts raise concerns about what the real vs perceived meaning of DNR orders.

Introduction/background: Do not resuscitate (DNR) orders have been associated with higher mortality in hospitalized patients which the question if they these patients are victims of the self-fulfilling prophecy; that the odds of their survival is made worse by withholding aggressive treatment. In addition, previous reports show that racial and ethnic minorities tend to opt for more aggressive and lifesaving procedures as compared to Whites. Methods: We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all subarachnoid hemorrhage (ICH) patients. DNR code status was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, length of stay) were compared between the two groups. DNR code status was compared between different racial groups. Results: Of the 325923 patients with SAH, 20127 (6.17%%) had DNR order. SAH patients with DNR order had higher proportion of females (61.7% versus 59.4%, P=0.0048) and were older (70.9 years versus 58.4 years, P Conclusions: While there may be other explanations at play, the higher mortality and shorter LOS suggest that early DNR orders do lead to the self-fulfilling prophecy. The lower proportion of DNR orders among minorities suggest a sociocultural aspect in accepting the concept of DNR. These two facts raise concerns about what the real vs perceived meaning of DNR orders.

BACKGROUND: In 2017, the US Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI), which created a portable and durable code status for use across its health care system. Patients who now have a durable do not resuscitate (DNR) status may undergo invasive procedures. Few studies have examined whether proceduralists discuss DNR status and document changes before procedures. OBJECTIVE: To assess baseline percentage of suspension of DNR before nonsurgical invasive procedures and determine whether an academic detailing intervention consisting of training proceduralists in the use of a template that allows rapid suspension of DNR status increases percentage of DNR acknowledgments. METHODS: Single-center, quasi-experimental pre- and postassessments were done in high-volume, procedural areas, including gastroenterology, cardiology, and interventional radiology, in a VA medical center. The primary outcome was the proceduralists’ documentation of DNR status acknowledgment before a nonsurgical invasive procedure at baseline and after the intervention. Logistic regression was used to compare percentage of DNR acknowledgment with time (before, after) and procedural area and assessing their interaction in the model. RESULTS: The interaction between department and time revealed wide variation in documentation of DNR acknowledgment. Examining the model predicted percentages from the interaction, preintervention percentages for gastroenterology, cardiology and interventional radiology were 46%, 75.6%, and 7.5%, respectively, and postintervention model predicted percentages were 53.5%, 91.7%, and 26.3%, respectively. Only the before vs after contrast for interventional radiology was significantly different. When all procedural areas were combined, the percentage of DNR acknowledgment significantly improved from 38.6% to 61.1% (P = .01). CONCLUSIONS: Before nonsurgical invasive procedures, the percentage of DNR acknowledgment was low but after, the intervention significantly improved. Further research is needed to assess its impact on patient-centered outcomes.

Background:Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.Aim:Examine the relationship between dementia, DNR timing, and end-of-life care intensity.Design:Observational cohort study.Setting/Participants:Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.Results:Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.Conclusions:Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

Not for Cardiopulmonary Resuscitation (No-CPR) orders, or the local equivalent, help prevent futile or unwanted cardiopulmonary resuscitation. The importance of unambiguous and readily available documentation at the time of arrest seems self-evident, as does the need to establish a patient’s treatment preferences prior to any clinical deterioration. Despite this, the frequency and quality of No-CPR orders remains highly variable, while discussions with the patient about their treatment preferences are undervalued, occur late in the disease process, or are overlooked entirely. This review explores the evolution of hospital patient No-CPR/Do Not Resuscitate decisions over the past 60 years. A process based on standardized resuscitation plans has been shown to increase the frequency and clarity of documentation, reduce stigma attached to the documentation of a No-CPR order, and support the delivery of medically appropriate and desired care for the hospital patient.

Background Anesthesiologists caring for patients with do-not-resuscitate (DNR) orders may have ethical concerns because of their resuscitative wishes and may have clinical concerns because of their known increased risk of morbidity/mortality. Patient heterogeneity and/or emphasis on mortality outcomes make previous studies among patients with DNR orders difficult to interpret. We sought to explore factors associated with morbidity and mortality among patients with DNR orders, which were stratified by surgical subgroups. Methods Exploratory retrospective cohort study in adult patients undergoing prespecified colorectal, vascular, and orthopedic surgeries was performed using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File data from 2010 to 2013. Among patients with preoperative DNR orders (ie, active DNR order written in the patient's chart before surgery), factors associated with 30-day mortality, increased length of stay, and inpatient death were determined via penalized regression. Unadjusted and adjusted estimates for selected variables are presented. Results After selection as above, 211,420 patients underwent prespecified procedures, and of those, 2755 (1.3%) had pre-existing DNR orders and met above selection to address morbidity/mortality aims. By specialty, of these patients with a preoperative DNR, 1149 underwent colorectal, 870 vascular, and 736 orthopedic surgery. Across groups, 36.2% were male and had a mean age 79.9 years (range 21-90). The 30-day mortality was 15.4%-27.2% and median length of stay was 6-12 days. Death at discharge was 7.0%, 13.1%, and 23.0% in orthopedics, vascular, and colorectal patients with a DNR, respectively. The strongest factors associated with increased odds of 30-day mortality were preoperative septic shock in colorectal patients, preoperative ascites in vascular patients, and any requirement of mechanical ventilation at admission in orthopedic patients. Conclusions In patients with DNR orders undergoing common surgical procedures, the association of characteristics with morbidity and mortality varies in both direction and magnitude. The DNR order itself should not be the defining measure of risk.

Background Confusion about what a do-not-resuscitate (DNR) order means, including its misinterpretation as "do not treat," has been extensively documented in the literature. Yet there is a paucity of research concerning nurses' perspectives on DNR orders. Purpose and design This mixed-methods study was designed to explore nurses' perspectives on the meaning and interpretation of DNR orders in relation to caring for hospitalized adults with such orders. Methods Direct care nurses on three units in a large urban hospital were asked to respond online to a case study by indicating how they would prioritize care based on the patient's DNR designation. These nurses were then invited to participate in open-ended interviews with a nurse researcher. Interviews were audiotaped, transcribed, and analyzed. Findings A total of 35 nurses responded to the case study survey. The majority chose to prioritize palliative care, despite no indication that any plan of care was in place. Thirteen nurses also completed a one-on-one interview. Analysis of interview data revealed this overarching theme: varying interpretations of DNR orders among nurses were common, resulting in unintended consequences. Participants also reported perceived variances among health care team members, patients, and family members. Such misinterpretations resulted in shifts in care, varying responses to deteriorating status, tension, and differences in role expectations for health care team members. Conclusions Nurses have opportunities to address misconceptions about care for patients with DNR orders through practice, education, advocacy and policy, and research.

Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age &gt, 85 years (adjusted odd ratios (AOR) 1.700, 1.027&ndash, 2.814), living in long-term care facilities (AOR 1.880, 1.066&ndash, 3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039&ndash, 4.358), &ldquo, medical staff would not be surprised if the patient died within 12 months&rdquo, (AOR 1.725, 1.193&ndash, 2.496), and patients&rsquo, family requesting palliative care (AOR 2.420, 1.187&ndash, 4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p &lt, 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p &lt, 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p &lt, 0.001), 30-day (p &lt, 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.

Introduction Patient-centered care is a core principle of the Canadian healthcare system. In order to facilitate patient-centered care, the documentation of a patient's medical goals and expectations is important, especially in the event of acute decompensation when an informed conversation with the patient may not be possible. The 'Goals of Care Discussion Form (GCF)' at Kingston Health Sciences Centre (KHSC) documents goals of care discussions between patients and healthcare providers. All patients admitted to the Internal Medicine service are expected to have this form completed within 24 hours of admission. Formal measurement of form completion at our center has not previously been done, though anecdotally this form is often incomplete. The purpose of this study is to quantify the rate of completion and assess quality of documentation of the GCF at KHSC. Methods This prospective chart review took place between August 25, 2018, and March 25, 2019. Charts were reviewed for the presence of a completed GCF, and the quality of notation was assessed, as appropriate. Given there are no existing tools for assessing the quality of a document such as the GCF, authors TC and JM created one de novo for this study. Extracted data included the amount of time elapsed between admission and completion of the GCF, whether the 'yes/no cardiopulmonary resuscitation (CPR)' order in the patient's chart aligned with their wishes as outlined on the GCF, and whether or not a patient's GCF was uploaded to the hospital's electronic medical record (EMR). Results Two hundred sixteen charts were reviewed. Of these, 136 (63.0%) had a complete GCF. The mean GCF quality score was 3.4/7 (95% CI [3.2, 3.6]). The mean time elapsed from admission to the completion of the GCF was 1.5 days (95% CI [0.6, 2.4]). There were 130 charts with both a complete GCF and a 'yes/no CPR' order, and of these, 20 (15.4%) showed a discrepancy. Eighty-six (63.2%) of the completed GCFs were uploaded to the EMR. Discussion and conclusions The rate of GCF completion at KHSC is noticeably higher than expected based on the previous literature. However, our assessment of the quality of completion indicates that there is room for improvement. Most concerning, discrepancies were found between the 'yes/no CPR' order in a patient's chart and their stated wishes on the GCF. Furthermore, less than two-thirds of completed GCFs were found to have been uploaded to the hospital's EMR. Given the emphasis on patient-centered care in the Canadian healthcare system, our findings suggest that improvement initiatives are needed with respect to documenting goals of care discussions with patients.

RESEARCH OBJECTIVE: A do‐not‐resuscitate (DNR) order informs health care providers of patients’ preference not to receive cardiopulmonary resuscitation if their breathing stops or their heart stops beating. The use of DNR orders has risen over the past few decades among older people and patients with terminal illnesses such as pancreatic cancer. However, evidence about whether DNR orders are associated with changes in utilization or cost savings is mixed. Here, we focus on pancreatic cancer due to its low survival rate resulting from late stage of diagnosis. The objective of this study was to evaluate whether DNR status had a significant association with mortality, length of stay (LOS), and costs of an inpatient stay among pancreatic cancer patients. STUDY DESIGN: This was an observational study using 2011‐2013 inpatient data from the Healthcare Cost and Utilization Project’s (HCUP) National Inpatient Sample (NIS). Patients with pancreatic cancer were identified using a primary ICD‐9‐CM diagnosis code of 52.0‐52.9. In addition, DNR status was identified using ICD‐9‐CM code of V49.86 (DNR status). This study compared three outcomes: mortality, LOS, and costs between patients with and without a DNR. Total costs were estimated using the cost‐to‐charge ratio and then inflated to 2015 USD using the Consumer Price Index. Univariate statistical analysis included t tests for continuous variables and chi‐squared tests for binary and categorical variables, respectively. We used logistic regression to estimate the association between of DNR and mortality, after controlling for other covariates. Total costs and LOS were modeled using generalized linear regression models and assumed gamma family of distributions and a log link function. To better control for covariate imbalance between patients with and without a DNR, we used propensity score matching. POPULATION STUDIED: A total of 7850 patients were admitted to a hospital with pancreatic cancer who were over 18 years old between 2011 and 2013, and DNR status was identified in 2.48% (n = 195). PRINCIPAL FINDINGS: Patients with older age, female, higher number of comorbidities, had Medicare as primary insurance, were admitted on an urgent or emergent basis, and treated in rural or urban nonteaching hospitals were more likely to have a DNR order. After controlling for all covariates, patients with a DNR had more than 8 times greater odds of mortality compared to patients without a DNR (OR = 8.14; P

Background To investigate the use of do-not-resuscitate (DNR) orders in patients hospitalized with community-acquired pneumonia (CAP) and the association with mortality. Methods We assembled a cohort of 1317 adults hospitalized with radiographically confirmed CAP in three Danish hospitals. Patients were grouped into no DNR order, early DNR order (≤48 h after admission), and late DNR order (> 48 h after admission). We tested for associations between a DNR order and mortality using a cox proportional hazard model adjusted for patient and disease related factors. Results Among 1317 patients 177 (13%) patients received a DNR order: 107 (8%) early and 70 (5%) late, during admission. Patients with a DNR order were older (82 years vs. 70 years, p Conclusion In this representative Danish cohort, 13% of patients hospitalized with CAP received a DNR order. DNR orders were associated with higher mortality after adjustment for clinical risk factors. Thus, we encourage researcher to take DNR orders into account as potential confounder when reporting CAP associated mortality.

Implementation of an acute bundle of care for intracerebral haemorrhage (ICH) was associated with a marked improvement in survival at our centre, mediated by a reduction in early (

This cross-sectional study examines the association between rates of mortality and readmission used by Medicare to determine financial penalties and to rank hospital quality with the case mix of patients with do-not-resuscitate status at US hospitals., Key Points Question Are risk-standardized mortality and readmission rates used in financial penalties and quality star ratings associated with the case mix of patients with do-not-resuscitate status in US hospitals? Findings In this cross-sectional study of mortality cohorts comprising 4 884 237 inpatient encounters and readmission cohorts including 4 450 378 inpatient encounters, hospitals with a greater relative volume of patients with present-on-admission do-not-resuscitate status had statistically significantly higher 30-day risk-standardized mortality rates and statistically significantly greater odds of avoiding a Hospital Readmission Reduction Program financial penalty. Meaning Results of this study suggest that risk-standardized hospital outcomes should control for do-not-resuscitate status to avoid potential biases in pay-for-performance programs and hospital quality rankings., Importance The Centers for Medicare and Medicaid Services’s (CMS’s) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings. Objective To identify the association between hospital-level DNR prevalence and condition-specific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty. Design, Setting, and Participants This cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis. Exposures Present-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions. Main Outcomes and Measures Hospital-level 30-day RSMRs and RSRRs for 5 condition-specific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no). Results Included in the study were 4 884 237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2 608 182 women [53.4%]) and 4 450 378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P

Objectives Code status specifies the action that healthcare providers should take in the event of cardiac arrest. Studies have shown, however, that patients with do-not-resuscitate/do-not-intubate (DNR/DNI) orders have worse outcomes and do not consistently receive the standard of care. Several studies have demonstrated that physicians behave differently toward patients with DNR/DNI orders, but little research exists into whether DNR/DNI status affects the practice of other members of the care team. Our objective was to determine whether code status affects decision making by nursing staff. Methods This was an anonymous, self-administered survey of nurses between April 2018 and March 2019 using SurveyMonkey. The survey contained four previously published clinical vignettes followed by a series of questions regarding specific interventions tailored to reflect nursing escalation of care. Our focus was two local hospitals: one large academic quaternary-referral center and one large community hospital. Registered nurses on medical-surgical units identified based on available unit-specific e-mail listservs from both hospitals were the participants. Nurses in higher-acuity units were excluded. Results Nurses are significantly less likely to call rapid response or a physician when a patient undergoes certain changes in clinical status if the patient is labeled as DNR/DNI rather than full code. For all of the vignettes, respondents were less likely to say they would call rapid response or a physician for patients with a DNR/DNI status who developed tachycardia (P 0.05). Nurses with >3 years of experience were less likely to escalate care throughout the vignettes (odds ratio Conclusions This study is the first to demonstrate that code status affects decision making by nursing staff. It highlights the limitations that code status designations create with regard to patient care. By acknowledging that patients with DNR/DNI orders receive different care, we can create systems in which patients are treated equally, regardless of their code status.