Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis
Open accessAbstract
Purpose Do-not-attempt-resuscitation (DNAR) orders are common in severe sepsis, but the impact on clinical care is not known. Our primary objective was to determine the impact of early DNAR orders on in-hospital mortality and performance of key interventional procedures among severe sepsis hospitalizations. Our secondary objective was to further investigate what patient characteristics within the sepsis DNAR population affected outcomes. Methods Using the 2010-2011 California State Inpatient Dataset, we analyzed hospitalizations for adults admitted through the emergency department with severe sepsis. Our primary predictor was a DNAR order, and our outcomes were in-hospital mortality and performance of interventional procedures. Results Visits with early DNAR orders accounted for 20.3% of severe sepsis hospitalizations. An early DNAR order was a strong, independent predictor of higher in-hospital mortality (odds ratio [OR], 4.03; 95% confidence interval, 3.88-4.19) and lower performance of critical procedures: central venous line (OR, 0.70), mechanical ventilation (OR, 0.80), hemodialysis (OR, 0.61), and major operative procedure (OR, 0.46). Among those with early DNAR orders, older age and rural location were the strongest predictors for a lack of interventional procedures. Conclusion Although DNAR orders are not synonymous with "do not treat," they may unintentionally limit aggressive treatment for severe sepsis patients, especially in older adults.
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The findings suggest a higher rate of DNACPR use (31%) than identified in previous studies of other respiratory conditions or sepsis.
“Our findings suggest a higher rate of DNACPR use (31%) than identified in previous studies of other respiratory conditions or sepsis.”
From Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study (2021) · cites this paper as [11]
The Results report early DNAR orders in 20.3% of severe sepsis hospitalizations, supporting the comparison of the citing authors’ 31% rate with a previous sepsis study. This paper does not provide a DNAR rate for other respiratory conditions, and its measure is specifically early orders rather than all DNACPR use. (LLM, conf=0.85)
Experimental — accuracy not yet measuredStudies in severe sepsis or septic shock reported rates of DNACPR use ranging from 9% to 20%.
“while studies in severe sepsis or septic shock reported rates ranging from 9% to 20%.11, 12, 13, 14”
Previous studies have estimated the prevalence of DNACPR decision in patients admitted to hospital with community-acquired pneumonia and sepsis, and have attempted to identify factors associated with DNACPR use, but we currently know very little about how DNACPR decisions have been used in people admitted with suspected COVID-19.
“Previous studies have estimated the prevalence of DNACPR decision in patients admitted to hospital with community-acquired pneumonia6, 7, 8, 9, 10 and sepsis,11, 12, 13, 14 and have attempted to identify factors associated with DNACPR use, but we currently know very little about how DNACPR decisions have been used in people admitted with suspected COVID-19.”
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Cites
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Cited by
Sorted by citations
Sutton, L., Goodacre, S., Thomas, B., & Connelly, S. (2021) · Resuscitation · doi:10.1016/j.resuscitation.2021.04.028 · Cited by 27 · see citing works
Recommended summary plan for emergency care and treatment: ReSPECT a mixed-methods study
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Do-not-resuscitate orders in patients with community-acquired pneumonia: a retrospective study
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- Authors
- Sarkari, N. N., Perman, S. M., & Ginde, A. A.
- Affiliations
- University of Colorado Anschutz (US)
- Corresponding author
- Ginde, Adit A.
- Venue
- Journal of Critical Care
- Publisher
- Elsevier BV
- Published
- 2016-12
- Volume
- 36
- Pages
- 134-139
- ISSN
- 0883-9441 (ISSN-L)
- PMC
- PMC5967875
- OpenAlex
- W2471877895
- Cited by
- 24
- References
- 2
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 3 · 2022: 3 · 2021: 1 · 2020: 3 · 2019: 4 · 2018: 2 · 2017: 2
- FWCI
- 2.64
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Journal of Critical Care (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (L30 HL134129)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (K12HD057022)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Sepsis Diagnosis and Treatment
- Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
- Keywords
- do-not-resuscitate orders, severe sepsis, in-hospital mortality, interventional procedures, central venous catheterization, mechanical ventilation, hemodialysis, older adults, rural patients, end-of-life decisions, emergency department hospitalization
- MeSH terms
- Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, California, Catheterization, Central Venous, Cross-Sectional Studies, Emergency Service, Hospital, Female, Renal Dialysis, Humans, Male, Middle Aged, Respiration, Artificial, Rural Population, Surgical Procedures, Operative, Time Factors, Databases, Factual, Advance Directives, Resuscitation Orders, Hospital Mortality, Sepsis, Young Adult
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