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ALIGNMENT OF DNR STATUS WITH PATIENTS’ LIKELIHOOD OF FAVORABLE
NEUROLOGICAL SURVIVAL AFTER IN-HOSPITAL CARDIAC ARREST
Timothy Fendler, MD; John A. Spertus, MD, MPH; Fengming Tang, MS; Paul S. Chan, MD, MSc
Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, MO
• Gaps in Knowledge:
— Lack of valid prediction tool for prognosis to inform DNR
discussions
— Unknown whether DNR status adoption is aligned with likelihood
of meaningful survival
• Recent Developments:
— The Cardiac Arrest Survival Post-Resuscitation In-Hospital
(CASPRI) score risk model strongly predicts likelihood of favorable
neurological survival after IHCA (c-statistic 0.802)
— Includes 11 variables: age, initial arrest rhythm, pre-arrest
neurological disability, hospital location of arrest, duration of
arrest, renal insufficiency, hepatic insufficiency, sepsis, malignant
disease, hypotension, need for mechanical ventilation
OBJECTIVE
• Evaluate whether DNR decisions after resuscitation from IHCA occur
primarily in patients with low likelihood of favorable neurological
survival, as per CASPRI score
RESULTS
RESULTS
FIGURE 1: PATIENT EXCLUSION FLOWCHART
TABLE 2: RATES OF SURVIVAL AND DNR
STATUS ADOPTION, BY DECILE
FIGURE 3: RATES OF FAVORABLE NEUROLOGICAL SURVIVAL
AMONG DNR & NON-DNR PATIENTS, STRATIFIED BY DECILE
Patients with cardiac arrest, n=72,875
Arrested outside inpatient & intensive care units, n=13,286
• Definition of Variables:
— DNR Status: order placed within 12 hours after achieving return of
spontaneous circulation from IHCA
— Favorable Neurological Survival: survival to discharge without
severe neurologic disability (Cerebral Performance Category [CPC]
1 or 2)
DISCLOSURES
• Dr. Fendler is supported by a T32 training grant (HL110837) from
the NHLBI
Overall
Survival Rate*
no. (%)
Died during resuscitation, n=25,618
Patients with cardiac arrest and ROSC, n=33,971
105 (1.8%)
6213 (30.5%)
1
1550 (64.7)
169 (7.1)
12 (7.1)
1538 (69.1)
2
834 (48.3)
181 (10.5)
11 (6.1)
823 (53.3)
3
892 (35.2)
372 (14.7)
18 (4.9)
874 (40.4)
4
937 (27.9)
601 (17.9)
11 (1.8)
926 (33.6)
5
389 (20.1)
398 (21.4)
9 (2.3)
380 (26.1)
6
679 (18.4)
890 (24.1)
23 (2.6)
656 (23.4)
7
262 (15.6)
465 (27.7)
4 (0.9)
258 (21.2)
8
347 (12.2)
749 (26.4)
4 (0.5)
343 (16.4)
9
320 (9.0)
1160 (32.5)
13 (1.1)
307 (12.7)
10
108 (4.1)
959 (36.0)
0 (0.0)
108 (6.3)
• Statistical Analysis:
— Baseline characteristics compared using standardized differences
(SD > 10% implies signi ficant between-group di fferences)
— CASPRI score calculated for each patient's likelihood of favorable
neurological survival
— Higher CASPRI scores indicate worse prognosis
— Stratified cohort into deciles of CASPRI score
— Compared rates of DNR and actual favorable neurological
survival, by decile
Age, mean ± SD
Female, no. (%)
Race, no. (%): White
Black
Other
CPC on admission, no. (%):
CPC 1
CPC 2
CPC 3
CPC 4
CPC 5
Hypotension, no. (%)
Respiratory insufficiency, no (%)
Renal insufficiency, no (%)
Hepatic insufficiency, no (%)
Metabolic/electrolyte abn, no (%)
Pneumonia, no (%) DNR
(n = 5944)
68.6 ± 15.2
2775 (46.7)
4310 (73.6)
1165 (19.9)
381 (6.5)
2436 (50.7)
1244 (25.9)
691 (14.4)
435 (9.0)
1 (0.0)
2065 (34.7)
2963 (49.8)
2499 (42.0)
661 (11.1)
1264 (21.3)
983 (16.5)
Non-DNR
(n = 20383)
64.2 ± 15.7
8663 (42.5)
13697 (68.3)
4726 (23.6)
1644 (8.2)
9802 (58.8)
4006 (24.0)
1895 (11.4)
956 (5.7)
5 (0.0)
5003 (24.5)
8864 (43.5)
7501 (36.8)
1622 (8.0)
3096 (15.2)
3112 (15.3)
Standardized
Differences (%)
28.47
8.43
11.79
8.88
6.47
16.42
4.25
8.98
12.68
0.58
22.47
12.78
10.74
10.78
15.79
14.18
*Standardized differences were < 10% for heart failure, myocardial infarction, arrhythmia, diabetes mellitus, central nervous system
depression, stroke, acute central nervous system non-stroke event, septicemia, and metastatic/hematologic malignancy
70
Survival Rate*
non-DNR Patients
no. (%)
5944 (22.6)
Patients not made DNR
n=20,383 (77.4%)
TABLE 1: BASELINE CHARACTERISTICS
Survival Rate*
DNR Patients
no. (%)
6318 (24.0)
Patients with complete data, n=26,327
Patients made DNR
n=5,944 (22.6%)
DNR Status
Adoption Rate
no. (%)
Overall
Missing CPC scores or DNAR data, n=7,644
METHODS
• Data Source: Get With the Guidelines - Resuscitation
— Multi-center, observational registry since 2001
— 125,000 patients with IHCA from 635 US hospitals
Decile
Non-DNR Patients
DNR Patients
60
50
40
30
20
10
0
1
2
3
4
5
6
7
CASPRI Score by Decile
8
9
10
LIMITATIONS
• Occurrence, frequency, and content of physician-patient
discussions about DNR status not measured
*Refers to rate of favorable neurological survival (CPC 1 or 2)
FIGURE 2: RATES OF DNR AND FAVORABLE NEUROLOGICAL
SURVIVAL, STRATIFIED BY DECILE
• Unmeasured confounders may mediate DNR decisions (i.e.,
terminal illness, personal beliefs, physician prognostic abilities)
• Unclear if DNR status is a marker or mediator of worse survival
60
Favorable Neurological Survival, %
DNR Status Adoption, %
50
Rate of Events, %
• In-hospital cardiac arrest (IHCA) occurs in ~200,000 patients
annually in the US
— Survival rate is ~22% among resuscitated patients
— Often prompts Do-Not-Resuscitate (DNR) discussions
METHODS
% of Patients
BACKGROUND
• Among patients resuscitated from IHCA, DNR decisions were
generally aligned with prognosis
40
30
• In patients with the worst prognosis, nearly 2/3 did not adopt DNR
status, yet still had very low favorable neurolgocial survival rates
20
• Of patients with the best prognosis, ~1 in 10 still adopted DNR
status, and had only ~1/10 the survival rate of non-DNR patients
10
0
CONCLUSIONS
1
2
3
4
5
6
CASPRI Score by Decile
7
8
9
10
• The CASPRI score may be a valuable prognostic aid for physicians
in discussing goals of care with survivors of IHCA