How Do We Align DNR Orders With Patient Preferences and Prognosis? Interview with: Dr. Timothy J. Interview with:
Dr. Timothy J. Fendler MD MS
Department of Cardiology,
Saint Luke’s Mid America Heart Institute
Kansas City, Missouri

Medical Research: What is the background for this study? What are the main findings?

Dr. Fendler: In-hospital cardiac arrest occurs commonly in the United States and is associated with low rates of meaningful survival. This poor prognosis should prompt patient-clinician discussions about goals of care and preferences for future resuscitative efforts. Little is known about how prognosis is aligned with code status decisions among survivors of in-hospital cardiac arrest (in other words, as prognosis worsens, are patients more likely to adopt Do-Not-Resuscitate orders, a sign of less aggressive treatment preferences, should recurrent cardiac arrest occur).

We found that, among patients who survive an in-hospital cardiac arrest, there is generally good alignment between prognosis and code status decisions. That is, as prognosis worsens among survivors of in-hospital cardiac arrest, the rate of DNR status adoption increases, on average.

However, among patients with very low levels of neurologic functioning and very poor prognosis, nearly two-thirds did not adopt DNR status, despite the fact that only about 4% of these patients with poor prognosis experienced actual favorable neurological survival. These results imply that there could be better alignment between prognosis and goals of care decisions that places the patient’s wishes, safety, and quality of life at the forefront of decision-making and decreases the likelihood of undue suffering when the outcome may not be improved by it.

Second, survival rates were much lower in patients with DNR orders, compared to those who did not adopt DNR status, after survival from in-hospital cardiac arrest. This was observed regardless of prognosis, implying that patients who adopt DNR status, and thus only request they be treated differently in the setting of recurrent cardiac arrest, may be receiving less aggressive treatment than they prefer, in areas of their care outside of resuscitation from cardiac arrest.

Medical Research: What should clinicians and patients take away from your report?

Dr. Fendler: Our results imply that, while our work to standardize resuscitation efforts for patients during in-hospital cardiac arrest has been exhaustive, little attention has been paid to how we assign prognosis, share that prognosis with patients, and help those patients to make treatment decisions reflective of their goals and preferences, after survival form cardiac arrest. Patients who survive in-hospital cardiac arrest might not understand that likelihood of “good” survival may be influenced by a number of factors about their pre-arrest state, comorbidities, and aspects of the arrest event itself, and may not have a good sense of what their prognosis is, which could help them make the best decisions for themselves. DNR decisions should be personal to each patient; there is not a right or wrong choice for any one situation. However, our findings imply that perhaps some patients would benefit from better understanding of these complex issues before deciding about aggressiveness of future care.

Our findings should spur on further studies about what patients want after surviving cardiac arrest and how clinicians can best estimate prognosis, share it with patients and/or their families, and support informed decision-making in the post-arrest period about goals of care based on individual patient preferences and goals. clinicians should strive to increase prognostic skills in complex clinical scenarios such as resuscitation from in-hospital cardiac arrests so they can best educate patients, ensure informed decisions, and advocate for patients’ beliefs and goals.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Fendler: The CASPRI score should be validated in other groups of patients who have survived cardiac arrest, as it may prove to be a useful tool in helping clinicians estimate prognosis and support patients’ decisions about their future care. Furthermore, our working research group is currently studying hospital rates of DNR status adoption and survival among patients resuscitated from cardiac arrest. The implications for a hospital-level analysis like this may be more for policy and procedural changes in how hospitals address and carry out patients’ code status preferences, and to ensure all patients are treated according to their preferences, regardless of where they seek care.

The use of this large, national registry of in-hospital cardiac arrest to carry out our study means that we could not get really granular details about each case, such as whether code status discussions occurred between clinicians and patients or their families, what the content if such discussions was, if they did occur, and what ultimately led patients or their families to adopt DNR status or not. Such information is key to better understanding the reasons behind some of the more provocative trends we discovered in our research. Future work in this area would benefit from more qualitative research methods, such as interviews of key stakeholders, direct observation of discussions/meetings about goals of care for patients who have survived cardiac arrest, and acquisition of data points that are not normally collected in traditional healthcare registries (for example, questions that can only be answered by talking directly with patients and/or clinicians).

Finally, I think our study is timely and important because it fits in (indirectly) with the larger narrative that is currently unfolding in our healthcare system, regarding how we approach critical and/or terminal illness and end-of-life decision making (though all of our patients were not end-of-life) in our current healthcare system. While we have focused heavily in the past on the quality of how we live with chronic diseases and illness, less emphasis has been placed on understanding and improving the process of how we die. Both are important. Studies like ours, which we think can help us think about how to study the ways clinicians, patients and families make difficult decisions in response to traumatic events such as in-hospital cardiac arrest and declines in their health, can prompt future research that might further the national conversation about supporting patient-centered healthcare and informed decision making, and improving the experience of patients at all phases of health, illness, and disease progression. 


Alignment of Do-Not-Resuscitate Status With Patients’ Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest

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Dr. Timothy J. Fendler (2015). How Do We Align DNR Orders With Patient Preferences and Prognosis? 

Last Updated on September 22, 2015 by Marie Benz MD FAAD