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Cited by 24Palliative Care and End-of-Life IssuesCardiac Arrest and ResuscitationPalliative and Oncologic Care

Factors associated with combined do-not-resuscitate and do-not-intubate orders: a retrospective chart review at an urban tertiary care center

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Stream, Sara, Nolan, Anna, Kwon, Sophia, Constable, Catherine·2018·Resuscitation
DOI 10.1016/j.resuscitation.2018.06.020PMC PMC6481924
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Abstract

Background In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders. Objective To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders. Design Retrospective chart review. Setting/subjects Patients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period. Measurements Logistic regression was used to identify demographic and medical data associated with code status. Results Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00). Conclusions Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.

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  • Evidence from systematic reviews suggests that advance care planning is associated with improvements in symptom control and quality of life.

    “Evidence from systematic reviews suggests that advance care planning is associated with improvements in symptom control and quality of life. 9,30,31,37,38,50,59”

    From European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions (2021) · cites this paper as [30]

    The Introduction discusses advance directives as a way to honor patients’ treatment preferences, and the Results report associations between DNR/DNI orders and treatments near death. Neither section reports systematic-review evidence that advance care planning improves symptom control or quality of life. Searches for those outcomes and related palliative-care terms found no supporting passage in our copy. (LLM, conf=0.75)

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1 of the 39 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. [25]Mirarchi FL, Doshi AA, Zerkle SW, Cooney TE. TRIAD VI: how well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms? J Patient Saf 2015; 11: 1– 8. 25692502
  2. [26]Mirarchi FL, Cammarata C, Zerkle SW, Cooney TE, Chenault J, Basnak D. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? J Patient Saf 2015; 11: 9– 17. 25692503

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Authors
Stream, S., Nolan, A., Kwon, S., & Constable, C.
Affiliations
  • NYU Langone Health (US)
  • New York University (US)
Corresponding author
Constable, Catherine
ORCID
Venue
Resuscitation
Publisher
Elsevier BV
Published
2018-09
Volume
130
Pages
1-5
ISSN
0300-9572 (ISSN-L)
DOI
10.1016/j.resuscitation.2018.06.020
PMC
PMC6481924
OpenAlex
W2808953724
Cited by
24
References
39
Citations by year
2025: 4 · 2024: 1 · 2023: 2 · 2021: 8 · 2020: 7 · 2019: 2
FWCI
3.92
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Resuscitation (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Heart, Lung, and Blood Institute (R01HL119326)
  • National Institute for Occupational Safety and Health (U01-OH011300)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
Keywords
do-not-resuscitate orders, do-not-intubate orders, code status, end-of-life care, advance directives, Charlson Comorbidity Index, cancer, morphine, patient age, sex differences, last days of life, code status discussions
MeSH terms
Adult, Aged, Female, Heart Arrest, Humans, Intubation, Intratracheal, Male, Middle Aged, Patient Care Planning, Retrospective Studies, United States, Advance Directives, Resuscitation Orders, Withholding Treatment, Current Procedural Terminology, Quality Improvement, Tertiary Care Centers

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