Impact of frailty on do-not-resuscitate orders and healthcare transitions among elderly Koreans with pneumonia
Open accessAbstract
Purpose: Pneumonia poses a significant health risk in aging societies. We aimed to elucidate the determinative value of frailty for do-not-resuscitate (DNR) orders in pneumonia patients. Patients and methods: This was a retrospective cohort study conducted at the Seoul National University Bundang Hospital (SNUBH) in Korea. Medical records of 431 pneumonia patients, aged 65 years and older, who were admitted between June 2014 and May 2015 were analyzed. Patients were categorized into DNR and no-DNR groups. Results: Among the 65 patients (15.1% of pneumonia patients) who completed DNR documents, 24 patients were survived, and 21 patients decided imminent to death (<24 hours before death), with all decisions determined by surrogates. The DNR group tended to be older and frail, with higher rates of renal impairment and malnutrition, and had a lower microbiology detection effort than the no-DNR group. The DNR group used a high number of broad-spectrum antibiotics, experienced high levels of in-hospital (63.1% vs 5.7%, P <0.001) and 30-day (64.6% vs 9.6%, P <0.001) mortality rates, and had prolonged hospital stays (median length of hospital stay, 12 vs 9 days, P =0.020). Frailty was independently associated with DNR status even after adjustment for sepsis, septic shock, and the pneumonia severity index (PSI) score. Frailty also significantly influenced healthcare setting transitions after adjustment for sepsis, septic shock, and the PSI. Conclusion: We identified the factors associated with DNR orders and their prognoses among elderly Koreans with pneumonia. Frailty was significantly associated with DNR decision and healthcare setting transitions in pneumonia patients. Keywords: do-not-resuscitate, end-of-life care, frailty index
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Abe et al, Becker et al and Choi et al identified DNACPR decisions within the hospitalisation period.
“More broadly, Abe et al,28 Becker et al29 and Choi et al30 identify DNACPR decisions within the hospitalisation period”
From Do not attempt cardiopulmonary resuscitation decision-making process: scoping review (2025) · cites this paper as [30]
No patient with a DNACPR order provided written informed consent by themselves.
“No patient with a DNACPR order provided written informed consent by themselves.30”
From Do not attempt cardiopulmonary resuscitation decision-making process: scoping review (2025) · cites this paper as [30]
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Cites
The third international consensus definitions for sepsis and septic shock (Sepsis-3).
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J.-D., Coopersmith, C. M., et al. (2016) · JAMA · doi:10.1001/jama.2016.0287 · Cited by 28,250 · see citing works
Frailty in Older Adults: Evidence for a Phenotype
Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop, W. J., Burke, G., et al. (2001) · The Journals of Gerontology Series A: Biological Sciences and Medical Sciences · doi:10.1093/gerona/56.3.m146 · Cited by 24,907 · see citing works
Bone, R. C., BALK, R. A., Cerra, F. B., Dellinger, R. P., Fein, A. M., Knaus, W. A., Schein, R. M. H., & Sibbald, W. J. (1992) · CHEST Journal · doi:10.1378/chest.101.6.1644 · Cited by 13,192 · see citing works
Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., & Rockwood, K. (2013) · The Lancet · doi:10.1016/s0140-6736(12)62167-9 · Cited by 9,503 · see citing works
A global clinical measure of fitness and frailty in elderly people
Rockwood, K. (2005) · Canadian Medical Association Journal · doi:10.1503/cmaj.050051 · Cited by 8,968 · see citing works
A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia
Fine, M. J., Auble, T. E., Yealy, D. M., Hanusa, B. H., Weissfeld, L. A., Singer, D. E., Coley, C. M., Marrie, T. J., & Kapoor, W. N. (1997) · New England Journal of Medicine · doi:10.1056/nejm199701233360402 · Cited by 4,560 · see citing works
A standard procedure for creating a frailty index
Searle, S. D., Mitnitski, A., Gahbauer, E. A., Gill, T. M., & Rockwood, K. (2008) · BMC Geriatrics · doi:10.1186/1471-2318-8-24 · Cited by 3,568 · see citing works
Lim, W. S. (2003) · Thorax · doi:10.1136/thorax.58.5.377 · Cited by 3,066 · see citing works
Clegg, A. P., Bates, C. J., Young, J. B., Ryan, R. P., Nichols, L., Teale, E. A., Mohammed, M. A., Parry, J., & Marshall, T. P. (2016) · Age and Ageing · doi:10.1093/ageing/afw039 · Cited by 1,308 · see citing works
Ekerstad, N., Swahn, E., Janzon, M., Alfredsson, J., Löfmark, R., Lindenberger, M., & Carlsson, P. (2011) · Circulation · doi:10.1161/circulationaha.111.025452 · Cited by 357 · see citing works
Health Values of Hospitalized Patients 80 Years or Older
Tsevat, J. (1998) · JAMA · doi:10.1001/jama.279.5.371 · Cited by 287 · see citing works
Hakim, R. B., Teno, J. M., Harrell, F. E., Jr., Knaus, W. A., Wenger, N., Phillips, R. S., Layde, P., Califf, R. M., Connors, A. F., Lynn, J., et al. (1996) · Annals of Internal Medicine · doi:10.7326/0003-4819-125-4-199608150-00005 · Cited by 266 · see citing works
Jung, H., Kim, S., Ahn, S., Lim, J., Han, J.-W., Kim, T. H., Kim, K., Kim, K.-I., & Kim, C.-H. (2014) · PLoS ONE · doi:10.1371/journal.pone.0087958 · Cited by 122 · see citing works
Self-citationChong, E. K. C., Ho, E. P. Y., Baldevarona-Llego, J., Chan, M. Y., Wu, L., Tay, L., Ding, Y. Y., & Lim, W. S. (2017) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2017.10.006 · Cited by 119 · see citing works
Clegg, A. P., Bates, C. J., Young, J. B., Ryan, R. P., Nichols, L., Teale, E. A., Mohammed, M. A., Parry, J., & Marshall, T. P. (2017) · Age and Ageing · doi:10.1093/ageing/afx001 · Cited by 102 · see citing works
Do Specialists Differ on Do-Not-Resuscitate Decisions?
Kelly, W. F., Eliasson, A. H., Stocker, D. J., & Hnatiuk, O. W. (2002) · CHEST Journal · doi:10.1378/chest.121.3.957 · Cited by 79 · see citing works
CPR or DNR? End-of-life decision in Korean cancer patients: a single center’s experience
Oh, D., Kim, J.-H., Kim, D.-W., Im, S., Kim, T., Heo, D. S., Bang, Y., & Kim, N. K. (2005) · Supportive Care in Cancer · doi:10.1007/s00520-005-0885-5 · Cited by 78 · see citing works
Do-Not-Resuscitate Orders for Terminal Patients with Cancer in Teaching Hospitals of Korea
Kim, D. Y., Lee, K. E., Nam, E. M., Lee, H., Lee, K., Kim, J. H., Lee, J. S., & Lee, S. N. (2007) · Journal of Palliative Medicine · doi:10.1089/jpm.2006.0264 · Cited by 67 · see citing works
Association of do-not-resuscitate orders and hospital mortality rate among patients with pneumonia
Walkey, A. J., Weinberg, J., Wiener, R. S., Cooke, C. R., & Lindenauer, P. K. (2016) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2015.6324 · Cited by 61 · see citing works
Lo, Y., Wang, J., Liu, L., & Wang, C.-N. (2010) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2009.10.006 · Cited by 49 · see citing works
Community-acquired pneumonia and do not resuscitate orders
Marrie, T. J., Fine, M. J., Kapoor, W. N., Coley, C. M., Singer, D. E., & Obrosky, D. S. (2002) · Journal of the American Geriatrics Society · doi:10.1046/j.1532-5415.2002.50061.x · Cited by 49 · see citing works
Family Involvement in End‐of‐Life Hospital Care
Tschann, J. M., Kaufman, S. R., & Micco, G. P. (2003) · Journal of the American Geriatrics Society · doi:10.1046/j.1365-2389.2003.51266.x · Cited by 39 · see citing works
Clinical implication of frailty assessment in older patients with atrial fibrillation
Kim, S., Yoon, S.-J., Choi, J., Kang, M., Cho, Y., Oh, I., Kim, C., & Kim, K. (2016) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2016.12.001 · Cited by 37 · see citing works
Self-citationDo-Not-Resuscitate Orders in the Last Days of Life
Bailey, F. A., Allen, R. S., Williams, B. R., Goode, P. S., Granstaff, S., Redden, D. T., & Burgio, K. L. (2012) · Journal of Palliative Medicine · doi:10.1089/jpm.2011.0321 · Cited by 37 · see citing works
Mehta, A., Cooke, C. R., Douglas, I. S., Lindenauer, P. K., Wiener, R. S., & Walkey, A. J. (2016) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201608-617oc · Cited by 13 · see citing works
Oshitani, Y., Nagai, H., & Matsui, H. (2014) · Geriatrics & Gerontology International · doi:10.1111/ggi.12054 · Cited by 12 · see citing works
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Park, C. M., Kim, W., Rhim, H. C., Lee, E. S., Kim, J. H., Cho, K. H., & Kim, D. H. (2021) · BMC Geriatrics · doi:10.1186/s12877-021-02049-5 · Cited by 65 · see citing works
Infections in the older population: what do we know?
Schoevaerdts, D., Sibille, F., & Gavazzi, G. (2019) · Aging Clinical and Experimental Research · doi:10.1007/s40520-019-01375-4 · Cited by 43 · see citing works
Luo, J., Tang, W., Sun, Y., & Jiang, C.-Y. (2020) · BMJ Open · doi:10.1136/bmjopen-2020-038370 · Cited by 40 · see citing works
Functional status recovery trajectories in hospitalised older adults with pneumonia
Park, C. M., Dhawan, R., Lie, J. J., Sison, S. D. M., Kim, W., Lee, E., Kim, J. H., & Kim, D. H. (2022) · BMJ Open Respiratory Research · doi:10.1136/bmjresp-2022-001233 · Cited by 23 · see citing works
Nari, F., Park, E., Nam, C. M., & Jang, S. (2023) · Scientific Reports · doi:10.1038/s41598-023-48403-y · Cited by 21 · see citing works
Pharmacotherapy of Lower Respiratory Tract Infections in Elderly—Focused on Antibiotics
Liu, Y., Zhang, Y., Zhao, W., Liu, X., Hu, F., & Dong, B. (2019) · Frontiers in Pharmacology · doi:10.3389/fphar.2019.01237 · Cited by 21 · see citing works
Lee, S., Ju, Y.-R., Kang, D. H., & Lee, J. E. (2024) · BMC Palliative Care · doi:10.1186/s12904-024-01375-w · Cited by 15 · see citing works
Do not attempt cardiopulmonary resuscitation decision-making process: scoping review
Doody, O., Davidson, H., & Lombard, J. (2025) · BMJ Supportive & Palliative Care · doi:10.1136/spcare-2023-004573 · Cited by 10 · see citing works
“51 Proactive discussion 35 can allow the person to fully participate in the decision 30 ; it also ensures that familiar healthcare professionals are involved in the conversation.”
BackgroundInfluentialEnd-of-Life Infections and the Dilemma of Emerging Antimicrobial Resistance: A Scoping Review
Alwazzeh, M. J. (2025) · Infection and Chemotherapy · doi:10.3947/ic.2024.0088 · Cited by 5 · see citing works
Ruisch, J. E., Sipers, W. M. W. H., Plum, P. F., & Spaetgens, B. (2020) · Geriatrics and gerontology international/Geriatrics & gerontology international · doi:10.1111/ggi.14030 · Cited by 5 · see citing works
Lombard, J., Davidson, H., & Doody, O. (2024) · Resuscitation Plus · doi:10.1016/j.resplu.2024.100799 · Cited by 2 · see citing works
Lu, Y., Chen, S., Wan, J., Chen, H., & Wu, S. (2026) · Experimental Gerontology · doi:10.1016/j.exger.2026.113179 · Cited by 1 · see citing works
Navigating the Ethical Crossroads of Suicide Attempts and End-of-Life Directives
Nemetz, E. T. A., & Huang, R. S. (2025) · Canadian Journal of Bioethics · doi:10.7202/1118914ar
Lee, S.-I., Ju, Y.-R., Kang, D. H., & Lee, J. E. (2024) · Figshare · doi:10.6084/m9.figshare.25223452
- Authors
- Choi, J.-Y., Kim, S.-W., Yoon, S.-J., Kang, M.-G., Kim, K.-I., & Kim, C.-H.
- Affiliations
- Seoul National University Bundang Hospital (KR)
- Kangwon National University Hospital (KR)
- Corresponding author
- Kim, Kwang-il
- Venue
- Clinical Interventions in Aging
- Publisher
- Informa UK Limited
- Published
- 2018-11
- Volume
- Volume 13
- Pages
- 2237-2245
- ISSN
- 1176-9092 (ISSN-L)
- 1178-1998
- PMC
- PMC6219099
- OpenAlex
- W2899023624
- Cited by
- 14
- References
- 26
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 4 · 2023: 1 · 2022: 1 · 2021: 1 · 2020: 2 · 2019: 2
- FWCI
- 1.19
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Clinical Interventions in Aging (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Dove Medical Press (Taylor and Francis Group) (submittedVersion, cc-by-nc)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Health Sciences › Medicine › Epidemiology › Pneumonia and Respiratory Infections
- Keywords
- frailty, do-not-resuscitate orders, pneumonia, elderly patients, transition to adult care, end-of-life care, frailty index, sepsis, septic shock, Pneumonia Severity Index, broad-spectrum antibiotics, length of hospital stay, mortality, surrogate decision-making, renal dysfunction, malnutrition
- MeSH terms
- Aged, Aged, 80 and over, Decision Making, Female, Hospitals, University, Humans, Male, Middle Aged, Patient Transfer, Pneumonia, Retrospective Studies, Shock, Septic, Cohort Studies, Comorbidity, Frail Elderly, Resuscitation Orders, Hospital Mortality, Third-Party Consent, Republic of Korea
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