Journal of the Formosan Medical Association
Volume 109, Issue 3 , Pages 201-208, March 2010

Survey of Do-not-resuscitate Orders in Surgical Intensive Care Units

  • Yu-Chen Huang

      Affiliations

    • Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
    • ,
  • Sheng-Jean Huang

      Affiliations

    • Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
    • Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
    • Department of Surgery, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
    • ,
  • Wen-Je Ko

      Affiliations

    • Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
    • Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
    • Corresponding Author InformationCorrespondence to: Dr Wen-Je Ko, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan

Received 13 February 2009; received in revised form 19 May 2009; accepted 17 July 2009.

Article Outline

Background/Purpose

End-of-life decisions are always difficult and complex, especially in the surgical setting. This study examines the epidemiology of do-not-resuscitate (DNR) orders, and the clinical factors influencing DNR consent. The impact of DNR on treatment and resource use in the surgical intensive-care unit (ICU) is also assessed.

Methods

This retrospective observational study was performed at National Taiwan University Hospital, a tertiary medical center in Taipei. A total of 14,698 patients were admitted to the surgical ICUs between January 2003 and December 2006. Of these, 13,825 (94.1%) survived to ICU discharge and 873 (5.9%) died. Of those that died, 278 (1.9% of total patients) went home to die due to terminal stage illness and 595 (4.0 % of total patients) died in the ICU. All mortality patients were included in this study.

Results

Yearly DNR rates were all above 65%. The average interval from ICU admission to DNR consent remained stable at 11–13 days, but the interval from DNR consent to death increased over the study period, from 2.0 to 3.5 days. Discussion over DNR was mainly initiated by intensivists. Multivariate logistic regression analysis found that older age (odds ratio, 1.010; p = 0.017) was significantly associated with DNR consent. DNR patients had longer ICU stays, lower fraction of inspired oxygen, and less inotropic infusion, dialysis, transfusion, laboratory examination, and chest radiography, but more use of sedative drugs, analgesics, and nutrition support at the time of death. After DNR, the use of advanced antibiotics, chest radiography, laboratory examination, and transfusion decreased. Inotropic infusion, however, continued to significantly increase.

Conclusion

Although DNR was common in our surgical ICU patients, this request was signed late in the ICU course, when therapeutic options had been exhausted. Early initiation of DNR discussion should be promoted to improve end-of-life care and reduce futile treatments in the ICU.

Key Words:  do-not-resuscitate , mortality , surgical intensive care unit , treatment intensity

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References 

  1. Asch DA , Hansen-Flaschen J , Lanken PN . Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physi cians' practices and patients' wishes . Am J Respir Crit Care Med . 1995;151:288–292
  2. Faber-Langendoen K . A multi-institutional study of care given to patients dying in hospitals: ethical and practice implications . Arch Intern Med . 1996;156:2130–2136
  3. Hofmann JC , Wenger NS , Davis RB , et al.   Patient prefer ences for communication with physicians about end-of-life decisions: SUPPORT Investigators; study to understand prognoses and preference for outcomes and risks of treat ment . Ann Intern Med . 1997;127:1–12
  4. Bacchetta MD , Eachempati SR , Fins JJ , et al.   Factors influ encing DNR decision-making in a surgical ICU . J Am Coll Surg . 2006;202:995–1000
  5. Keenan SP , Busche KD , Chen LM . Withdrawal and withholding of life support in the intensive care unit: a comparison of teaching and community hospitals . Crit Care Med . 1998;26:245–251
  6. Phillips RS , Wenger NS , Teno J , et al.   Choices of seriously ill patients and cardiopulmonary resuscitation: correlated and outcomes. SUPPORT Investigators; study to understand prognoses and preference for outcomes and risks of treatment . Am J Med . 1996;100:128–137
  7. Stern SG , Orlowski JP . DNR or CPR—the choice is ours . Crit Care Med . 1992;20:1263–1272
  8. Barie PS , Bacchetta MD , Eachempati SR . The contemporary surgical intensive care unit. Structure, staffing, and issues . Surg Clin N Am . 2000;80:791–804
  9. Chen YS , Ko WJ , Lin FY , et al.   Preliminary result of an algorithm to select proper ventricular assist devices for high-risk patients with extracorporeal membrane oxygenation support . J Heart Lung Transplant . 2001;20:850–857
  10. Ko WJ , Lin CY , Chen RJ , et al.   Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock . Ann Thorac Surg . 2002;73:538–545
  11. Bedell SE , Pelle D , Maher PL , et al.   Do-not-resuscitate orders for critically ill patients in the hospital. How are they used and what is their impact? . JAMA . 1986;256:233–237
  12. Gleeson K , Wise S . The do-not-resuscitate order. Still too little too late . Arch Intern Med . 1990;150:1057–1060
  13. Maksoud A , Jahnigen DW , Skibinski CI . Do not resuscitate orders and the cost of death . Arch Intern Med . 1993;153:1249–1253
  14. Hall RI , Rocker GM . End-of-Life Care in the ICU: treatments provided when life support was or was not withdrawn . Chest . 2000;118:1424–1430
  15. Esteban A , Gordo F , Solsona JF , et al.   Withdrawing and withholding life sustaining treatment in the intensive care unit: a Spanish prospective multi-centre observational study . Intensive Care Med . 2001;27:1744–1749
  16. Zimmerman JE , Knaus WA , Sharpe SM . The use and implications of do not resuscitate orders in intensive care units . JAMA . 1986;255:351–356
  17. Daly BJ , Gorecki J , Sadowski A , et al.   Do-not-resuscitate practices in the chronically critically ill . Heart Lung . 1996;25:310–317
  18. Jayes RL , Zimmerman JE , Wagner DP . Do-not-resuscitate orders in intensive care units: current practices and recent changes . JAMA . 1993;270:2213–2217
  19. Jayes RL , Zimmerman JE , Wagner DP , et al.   Variations in the use of do-not-resuscitate orders in ICUS. Findings from a national study . Chest . 1996;110:1332–1339
  20. Parker JM , Landry FJ , Phillips YY . Use of do-not-resuscitate orders in an intensive care setting . Chest . 1993;104:1592–1596
  21. Rapoport J , Teres D , Lemeshow S . Resource use implications of do not resuscitate orders for intensive care unit patients . Am J Respir Crit Care Med . 1996;153:185–190
  22. Youngner SJ , Lewandowski W , McClish DK . ‘Do not resuscitate’ orders: incidence and implications in a medical intensive care unit . JAMA . 1985;253:54–57
  23. Cook DJ , Guyatt GH , Jaeschke R . Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill . JAMA . 1995;273:703–708

PII: S0929-6646(10)60043-5

doi:10.1016/S0929-6646(10)60043-5

Journal of the Formosan Medical Association
Volume 109, Issue 3 , Pages 201-208, March 2010

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