Effect of a do-not-resuscitate order on the quality of care in acute heart failure patients: a single-center cohort study

Shunsuke Kojima,1 Eiji Hiraoka,1 Junya Arai,1 Yosuke Homma,2 Yasuhiro Norisue,3 Osamu Takahashi,4 Taihei Soma,1 Toshihiko Suzuki,5 Masahiko Noguchi,6 Kentaro Shibayama,6 Kotaro Obunai,6 Hiroyuki Watanabe6 1Department of Internal Medicine, 2Department of Emergency Medicine, 3Department of Critical Care and Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu-city, Chiba 279-0001, Japan; 4Department of Internal Medicine, St Luke’s International Hospital, Chuo-ku, Tokyo 104-8560, Japan; 5Department of Nephrology, Endocrinology, and Diabetes, 6Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu-city, Chiba 279-0001, Japan Background: A do-not-resuscitate (DNR) order is reportedly associated with a decrease in performance measures, but it should not be applied to noncardiopulmonary resuscitation procedures. Good performance measures are associated with improvement in heart failure outcomes.Aim: To analyze the influence of DNR order on performance measures of heart failure at our hospital, where lectures on DNR order are held every 3 months.Design: Retrospective cohort study.Methods: The medical report of patients with acute heart failure who were admitted between April 2013 and March 2015 were retrospectively analyzed. We collected demographic data, information on the presence or absence of DNR order within 24 hours of admission, and inhospital mortality. Performance measures of heart failure, including assessment of cardiac function and discharge prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and beta-blocker for left ventricular systolic dysfunction and anticoagulant for atrial fibrillation, were collected and compared between groups with and without DNR orders.Results: In 394 total patients and 183 patients with left ventricular systolic dysfunction, 114 (30%) and 44 (24%) patients, respectively, had a DNR order. Patients with a DNR order had higher inhospital mortality. There were no significant differences between the two groups in terms of the four quality measures (left ventricular function assessment, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, and anticoagulant).Conclusion: DNR orders did not affect performance measures, but they were associated with higher inhospital mortality among acute heart failure patients. Keywords: do-not-resuscitate discussion, DNR order, acute heart failure, quality-of-care performance&nbsp