Alignment of DNR Status with Patients’ Likelihood of Favorable Neurological Survival after In- hospital Cardiac Arrest Timothy Fendler, MD, MS Cardiovascular.

Alignment of DNR Status with Patients’ Likelihood of Favorable

Neurological Survival after In-hospital Cardiac Arrest

Timothy Fendler, MD, MS

Cardiovascular Diseases Fellow

Disclosures

Timothy Fendler – none

Pre-Arrest• Identify High Risk

Patients• Alert Systems• Rapid Response

Teams

Intra-Arrest• ACLS• Adequate

Compressions• Good

Communication

Post-Arrest• ???

Background

• JCAHO mandate: discuss resuscitation preferences on admission to all US hospitals

• Well-documented preferences foster

– Open communication

– Patient-physician trust

– Mutual understanding

– Alleviation of stress/uncertainty

in the event of cardiac arrest

Background• DNR discussion are difficult

– Patient-clinican discord CPR mistakes– Adequate documentation lacking– Lack of validated prediction tool for prognosis

• CASPRI Score– “Cardiac Arrest Survival Post-Resuscitation In-hospital”

– Derived/validated in 42, 957 resuscitated patients

Research Question• Is DNR status adoption well-aligned with

likelihood of favorable neurological survival among survivors of in-hospital cardiac arrest?

Good Fair Poor0%

25%

50%

75%

100%

Prognosis

Rate

of D

NR

Definition of Variables• DNR status –DNR order placed within 12

hours after achieving ROSC from an in-hospital cardiac arrest

• Favorable Neurological Survival – CPC score of 1 or 2 at discharge

• Likelihood of FNS – CASPRI score– Divided cohort into deciles

Exclusion Flow Chart

Results

>3-5 d

>24 h-3 d

>12-24 h

0-12 h

Results

Summary

• DNR and prognosis were generally aligned among survivors of in-hospital cardiac arrest

• >2/3 patients with worst prognosis not made DNR• Only 6.3% of these experienced “good survival”

• ~1/10 patients with best prognosis made DNR • Survival rates 1/10th of those with best prognosis & not DNR

• DNR patients had same LoS & costs, regardless of prognosis

Conclusions• Decisions to become DNR among successfully

resuscitated patients after in-hospital cardiac arrest are generally aligned with prognosis

• Focus areas for potential improvement include patients with the worst and best prognoses

• Systematic use of a prognostic tool, such as CASPRI, may optimize DNR decision-making in the in-hospital, post-arrest setting

Extra Slides

Background• The CASPRI tool

– Includes 11 variables:

• Age Renal insufficiency• Initial arrest rhythm Hepatic insufficiency• Pre-arrest neurological disability Sepsis• Hospital location of arrest Malignant disease• Duration of arrest Hypotension• Need for mechanical ventilation

– Strongly predicts likelihood of favorable neurological survival after in-hospital cardiac arrest

• C statistic = 0.802 for discrimination

Background

Background

Limitations of Study

• Occurrence, frequency, & content of DNR discussions unknown

• Some DNR decisions may reflect unmeasured confounders

• Unknown if DNR status adoption is a marker or mediator of worse survival