M. Kisat1, T. Orouji1, P. Rhee1, T. O’Keeffe1, N. Kulvatunyou1, R. S. Friese1, H. Phelan2, B. A. Joseph1 1University Of Arizona,Tucson, AZ, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA
Introduction: Do not resuscitate (DNR) status affects end of life decision making. Physicians often initiate or participate in discussions regarding DNR status for patients whose care is considered futile. However, the impact of this decision on patient outcomes is poorly understood. The aim of this study was to evaluate the impact of DNR status on mortality and rate of complications.
Methods: A two year (2011-2012) retrospective analysis of the National Trauma Data Bank (NTDB) was performed. Trauma patients older than 65 years, admitted to the Intensive Care Unit, and who underwent a major surgical procedure were included. Patients who were transferred, intoxicated, arrived with no vital signs, or died in the ED, were excluded. Patients with DNR status were identified based on advanced directives for end of life care. Matched no-DNR controls were identified using propensity score matching, controlling for age, gender, race, injury severity score, comorbidities, abbreviated injury score for head, and admission vitals. Primary outcomes were mortality, complications, and failure to rescue (FTR). FTR was defined as death after complication. Missing data was accounted for by using missing value analysis and multiple imputation.
Results: A total of 3,744 patients (DNR: 1,872 vs No-DNR: 1,872) were included in the analysis. Average age was 81 ± 6 years (mean ± SD) and 47% of patients were male. Median (IQR) Injury Severity Score was 13 (9 – 21). Overall mortality rate was 27%, complication rate was 49%, and FTR rate was 17%. Patients with DNR status had significantly higher mortality rates (36% vs. 17%, p < 0.001), complication rates (53% vs. 44%, p < 0.001), and FTR rates (23% vs. 10%, p < 0.001) compared to the No-DNR group. On sub-analysis of complications, FTR was higher in DNR patients for major (13% vs 6%, p <0.001) and minor (10% vs. 4%, p < 0.001) complications.
Conclusion: DNR status is a patient’s or their surrogate’s wish to prohibit end of life cardiopulmonary resuscitation; however, findings of our study suggest less aggressive treatment followed by higher mortality and failure to rescue in patients with DNR status. Patients and families should be informed of ensuing higher complications and mortality associated with DNR status when discussing goals of care.