Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock
Open accessAbstract
OBJECTIVES: To assess the importance of including do-not-resuscitate status in critical care observational comparative effectiveness research. DESIGN: Retrospective analysis. SETTING: All California hospitals participating in the 2007 California State Inpatient Database, which provides do-not-resuscitate status within the first 24 hours of admission. PATIENTS: Septic shock present at admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We investigated the association of early do-not-resuscitate status with in-hospital mortality among patients with septic shock. We also examined the strength of confounding of do-not-resuscitate status on the association between activated protein C therapy and mortality, an association with conflicting results between observational and randomized studies. We identified 24,408 patients with septic shock; 19.6% had a do-not-resuscitate order. Compared with patients without a do-not-resuscitate order, those with a do-not-resuscitate order were significantly more likely to be older (75 ± 14 vs 67 ± 16 yr) and white (62% vs 53%), with more acute organ failures (1.44 ± 1.15 vs 1.38 ± 1.15), but fewer inpatient interventions (1.0 ± 1.0 vs 1.4 ± 1.1). Adding do-not-resuscitate status to a model with 47 covariates improved mortality discrimination (c-statistic, 0.73-0.76; p < 0.001). Addition of do-not-resuscitate status to a multivariable model assessing the association between activated protein C and mortality resulted in a 9% shift in the activated protein C effect estimate toward the null (odds ratio from 0.78 [95% CI, 0.62-0.99], p = 0.04, to 0.85 [0.67-1.08], p = 0.18). CONCLUSIONS: Among patients with septic shock, do-not-resuscitate status acts as a strong confounder that may inform past discrepancies between observational and randomized studies of activated protein C. Inclusion of early do-not-resuscitate status into more administrative databases may improve observational comparative effectiveness methodology.
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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.”
Studies 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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Research works printed but not linked: 25
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Sutton, L., Goodacre, S., Thomas, B., & Connelly, S. (2021) · Resuscitation · doi:10.1016/j.resuscitation.2021.04.028 · Cited by 27 · see citing works
“Sakari et al. 11 and Bradford et al. 12 reported that DNACPR decision were associated with lower rates of invasive procedures, while Powell et al. 13 reported no difference, and Huang et al. 14 reported a higher rate of arterial or central venous cannulation in those with a DNACPR decision.”
Do-not-resuscitate orders in patients with community-acquired pneumonia: a retrospective study
Egelund, G. B., Jensen, A. V., Petersen, P. T., Andersen, S. B., Lindhardt, B. Ø., Rohde, G., Ravn, P., & von Plessen, C. (2020) · BMC Pulmonary Medicine · doi:10.1186/s12890-020-01236-1 · Cited by 15 · see citing works
- Authors
- Bradford, M. A., Lindenauer, P. K., Wiener, R. S., & Walkey, A. J.
- Affiliations
- Boston University (US)
- Venue
- Critical Care Medicine
- Published
- 2014-09
- Volume
- 42
- Issue
- 9
- Pages
- 2042-2047
- ISSN
- 0090-3493 (ISSN-L)
- PMC
- PMC4266548
- OpenAlex
- W2071816587
- Cited by
- 43
- References
- 0
- Citations by year
- 2025: 1 · 2024: 3 · 2023: 1 · 2022: 2 · 2021: 4 · 2020: 2 · 2019: 6 · 2018: 4 · 2017: 7 · 2016: 9 · 2015: 2 · 2014: 2
- FWCI
- 6.63
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Critical Care Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (K01HL116768)
- National Cancer Institute (K07CA138772)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
- Keywords
- do-not-resuscitate status, septic shock, confounding, activated protein C, in-hospital mortality, end-of-life decisions, administrative databases
- MeSH terms
- Age Factors, Aged, Aged, 80 and over, California, Female, Fibrinolytic Agents, Health Status Indicators, Humans, Intensive Care Units, Male, Middle Aged, Protein C, Retrospective Studies, Shock, Septic, Resuscitation Orders, Hospital Mortality, Racial Groups, Comparative Effectiveness Research
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