Community-acquired pneumonia and do not resuscitate orders
Open accessAbstract
OBJECTIVES: From a cohort of patients with community-acquired pneumonia (CAP) who required admission to hospital, to describe the subset of patients having a do not resuscitate (DNR) order and to compare them with those who did not have such an order. DESIGN: Retrospective subset analysis of data from the pneumonia patient outcomes research team study. SETTING: Three hospitals in the United States and one in Canada. PARTICIPANTS: Hospitalized patients aged 18 and older with CAP. MEASUREMENTS: Sociodemographic features, severity of illness, antibiotic therapy, length of stay, mortality, admission to special care units, and mortality attributable to pneumonia. RESULTS: The 199 (14.9) of 1,339 inpatients with CAP who had a DNR order written within 24 hours of admission and an additional 96 (7.2) patients who had such an order written later were compared with the 1,044 who never had a DNR order. The 199 patients with an initial DNR and 96 later DNR were older (median age 81 and 78 vs 65 years, respectively; P< .001), more likely to be white (92.5 and 90.6 vs 84.8; P = .007), and more likely to have come from a nursing home or chronic care facility (53.8 and 31.3 vs 4.5; P< .001). The two DNR groups received more antibiotics for a longer time than the never DNR patients. The DNR patients had longer lengths of stay than the never DNR patients (medians 9 and 12 vs 7 days). There were 89 in-hospital deaths among the 1,339 patients, but only 11 of these were among patients who did not have a DNR order during the first 30 days (sensitivity, specificity, and positive and negative predictive values of a DNR order for in-hospital mortality were 87.6, 82.6, 26.4, and 98.9, respectively). The 90-day mortality rates were 43.2 for the initial DNR group, 61.5 in the later DNR group, and 4.7 for the never DNR group (P< .001). Pneumonia-attributable mortality accounted for most of the in-hospital deaths but did not differ by DNR status. Only 31.7 of the initial DNR patients and 24.0 of the later DNR patients were discharged home, versus 82.6 of the other patients (P< .001). In a multivariate analysis, the following were predictive of initial DNR: age, nursing home care, active cancer, dementia, neuromuscular disorders, altered mental status, low systolic blood pressure, tachypnea, abnormal hematocrit, abnormal blood urea nitrogen, and absence of alcohol or intravenous drug abuse. In similar analyses of DNR at any time, additional predictors included aspiration, low white blood count, chronic pulmonary disease, cerebrovascular disease, and congestive heart failure. CONCLUSION: Most in-hospital pneumonia deaths occur in patients who have a DNR order. DNR orders written within 24 hours of admission primarily reflect comorbid status, whereas DNR orders written later during hospitalization reflect the futility of care plus comorbidity.
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Studies of patients admitted with community-acquired pneumonia reported rates of DNACPR use ranging from 13% to 29%.
“Studies of patients admitted with community-acquired pneumonia reported rates of DNACPR use ranging from 13% to 29%,6, 7, 8, 9, 10”
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.”
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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Limitation de traitement, comorbidités et personnes âgées
de Decker, L. (2012)
- Authors
- Marrie, T. J., Fine, M. J., Kapoor, W. N., Coley, C. M., Singer, D. E., & Obrosky, D. S.
- Affiliations
- Dalhousie University (CA)
- University of Pittsburgh (US)
- Harvard University (US)
- Corresponding author
- Marrie, Thomas J.
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2002-02
- Volume
- 50
- Issue
- 2
- Pages
- 290-299
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- OpenAlex
- W1993976661
- Cited by
- 49
- References
- 21
- Citations by year
- 2025: 2 · 2024: 1 · 2023: 1 · 2022: 3 · 2021: 3 · 2020: 2 · 2018: 2 · 2017: 1 · 2016: 4 · 2015: 3 · 2014: 6 · 2013: 3 · 2012: 4
- FWCI
- 0.70
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Epidemiology › Pneumonia and Respiratory Infections
- Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
- Keywords
- community-acquired pneumonia, do-not-resuscitate orders, advance directives, in-hospital mortality, nursing home residents, length of hospital stay, antibiotic therapy, mortality prediction, end-of-life decisions, hospital admission outcomes, 90-day mortality
- MeSH terms
- Adult, Aged, Aged, 80 and over, Canada, Female, Humans, Male, Middle Aged, Outcome and Process Assessment, Health Care, Pneumonia, Retrospective Studies, Risk, United States, Comorbidity, Multivariate Analysis, Resuscitation Orders, Treatment Outcome, Hospital Mortality, Community-Acquired Infections
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