Chest
Ethics in Cardiopulmonary MedicineVariations in the Use of Do-Not-Resuscitate Orders in ICUs: Findings From a National Study
Section snippets
Hospital Selection
As part of the APACHE III study, we collected information from 42 ICUs at 40 hospitals. To represent ICU care in nonfederal US hospitals with more than 200 beds, we selected 26 hospitals using stratified random criteria based on number of beds, region, and teaching status. Fourteen nonrandomized hospitals, primarily university or tertiary care hospitals with an interest in the study, volunteered to participate. We collected data in 2 separate medical and surgical ICUs at 2 volunteer hospitals
RESULTS
We collected information for 17, 440 ICU admissions to 42 ICUs at 40 hospitals, including 818 patients who were readmitted to the ICU during their hospital stay. Data were available for an average of 415 (range, 299 to 499) unselected admissions to each ICU during an average period of 9.7 months (range 3–17 months). DNR orders were written in the ICU for 1, 577 (9%) of these admissions. For the 16, 662 who were not ICU readmissions, 1, 441 (8.7%) had DNR orders written; 1, 156 (6.9%) during the
DISCUSSION
The 42 ICUs in our study had observed DNR order rates during the first 7 days of ICU care that varied from 0.9 to 16.7% of ICU admissions over an average of 9.7 months. Much of this variation (49%, R2=0.49) across ICUs was due to clinically relevant patient characteristics. The most important factors associated with a DNR order are the patient's severity of physiologic abnormalities, age, admission diagnosis, and prior health status (Fig 1). These factors have been associated previously with
ACKNOWLEDGMENTS
We wish to acknowledge Stephen M. Shortell, PhD, Denise M. Rousseau, PhD, Robin R. Gillies, PhD, Kelly J. Devers, MD, and Joanne Duffy, DNSc, for their contributions to the nine ICU on-site analyses, and Beth C. Horowitz, MD, for help in editing the manuscript.
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Variation in decisions to forgo life-sustaining therapies in US ICUs
2014, ChestCitation Excerpt :By contrast, we found that race, and to some extent age, have variable effects on DFLST across ICUs. Overall, as in prior studies,9,10,30–33 black and other nonwhite patients were less likely than white patients to have DFLSTs. However, a novel finding of this study is that this effect is not conserved among all ICUs and, in fact, in a minority of ICUs, black patients were more likely to have DFLSTs.
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2012, ChestCitation Excerpt :In the case of SAPS 3 (20 variables), it may be that the statistical power of well-chosen variables cumulatively compensates for the noninclusion of DNR status in the same manner that the large number of variables used in APACHE IV (n = 142) obviates the need for inclusion of DNR status. We did not explore the spectrum of limitations of care that occurs in our institution and throughout the United States, ranging from comfort measures only to full support up until the point of cardiac arrest.38,40,41,46,49,50 For the purposes of our evaluation, we chose the presence or absence of a DNR order.
Impact of age on mortality in patients with acute traumatic spinal cord injury requiring intensive care
2012, Annales Francaises d'Anesthesie et de ReanimationBenchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States
2011, ChestCitation Excerpt :Despite evidence that a DNR order is associated with lower probability of referral to an ICU32 and a lower OR for acceptance to a medical ICU,33 DNR orders were not uncommon among the critically ill adults of this study. Nearly 7% of patients had DNR orders at ICU admission, similar to the rate of 6.9% reported for DNR orders written within the first week of ICU stay in a 1996 study of 42 ICUs.34 Rates of care limitation orders at the time of admission were similar among all ICU types but were slightly higher in medical, neurosciences, and mixed ICUs than in surgical or trauma ICUs.
Survey of Do-not-resuscitate Orders in Surgical Intensive Care Units
2010, Journal of the Formosan Medical Association
Supported by the Agency for Health Care Policy and Research (HSO 5787), The John A. Hartford Foundation (87267), The Department of Anesthesiology, George Washington University Medical Center, and APACHE Medical Systems Inc.
All the authors certify that affiliations with or involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in this article are disclosed as follows: Drs. Knaus, Zimmerman, and Wagner are founders and minority equity shareholders of APACHE Medical Systems, Inc, a for-profit Delaware-based corporation that funded, in part, the research for the APACHE III® study. APACHE Medical Systems markets a software-based clinical information system based on some of the concepts described in this article. Drs. Knaus, Zimmerman, and Wagner receive financial support in the form of research grants from APACHE Medical Systems.