Do Not Resuscitate: What Is It?

-Medical Humanities Senior Honors Project-

Dr. Shanojan Thiyagalingam

Research Mentor: Dr. Nirav Mistry
Medical Humanities Mentor: Dr. Phyllis DeJesse

Study Co-authors: Nikhil Shah BA, Nirav Mistry MD, Jordan Resnick MD, Saad Amin MD, Saima Manzoor MD, Kristin Fless MD, Fariborz Rezai MD, Vagram Ovnanian MD, Paul Yodice MD
 Outline
• Background
• Case #1
• Methods
• Results
• Discussion
• Case #2
• Limitations
• Future Directions
 Background
• Do-Not-Resuscitate (DNR) patients in acute setting
• poorer outcomes compared to non-DNR patients 1,2,3

• Is it ethically right to provide aggressive medical care for the DNR

population despite high mortality?

• Study: investigate outcomes of patients with DNR status on admission

1 Saha, D., Moreno, C., Csete, M., et. al. (2016). Outcomes of Patients Who Have Do Not Resuscitate Status prior to Being Admitted to an Intensive Care Unit. Scientifica, 2016, 1-3.
doi:10.1155/2016/1513946
2 Decker, L. D., Annweiler, C., & Launay, C. (2014). Do not resuscitate orders and aging: Impact of multimorbidity on the decision-making process. The Journal of Nutrition, Health & Aging, 18(3), 330-335.

doi:10.1007/s12603-014-0023-5
3 Patel, K., Sinvani, L., Patel, V., et. al. (2018). Do-Not-Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score-Matched Analysis. Journal of the American Geriatrics Society, 66(5),

924-929. doi:10.1111/jgs.15347
 Case #1
• 100 y/o woman
• DNR, DNI
• Contracted, sarcopenic, dementia, bed-bound, minimally verbal,
heart failure
• UTI septic shock
• PMD requests vasopressor support
 Case #1
• 100 y/o woman
• DNR, DNI
• Contracted, sarcopenic, dementia, bed-bound, minimally verbal,
heart failure
• UTI septic shock
• PMD requests pressor support
• ICU consulted for septic shock
• Goals of care discussion—conservative, nonaggressive measures
• Transitioned to hospice
 Methods
• Large single center tertiary community academic medical center

• Retrospective review of electronic medical records

• January 1, 2017 to June 30, 2017

• 12 572 in-patients evaluated; 538 included

• Statistical methods
• Chi-square, independent sample t-tests, 95% confidence interval
 Methods
12 572 Medical Records
Inclusion criteria: age >21*, DNR on admission

Exclusion criteria: incomplete charting,

recurrent hospital admissions,
pregnant woman, minors*

538 Medical Records

 Methods
Demographics/
Comorbidities

• Survived vs. Died

Cohorts
538 Patients • ICU vs Non-ICU
538
Medical Records • Palliative services
Primary • Length of stay
Outcomes • Cost of hospitalization
• Hospital mortality

Secondary • Critical care intervention

Outcomes • Critical care mortality
 Results: Primary Outcome
Overall Mortality versus DNR Mortality
30

25
24.5%
% Mortality
20

15

10

5
2.05%
0
Overall Hospital Mortality DNR Mortality

Cohort
 Results: Primary Outcome
Palliative Service Utilization

Hospice 29.2%
Type of Service

Chaplaincy 32.5%

Palliative Care 45.2%

0 5 10 15 20 25 30 35 40 45 50

% Utilization
 Results: Primary Outcome
Cost Per Day of Hospitalization
Hospital Length of Stay 4000
7

6
6

5 3000
5
$2,567.80

Cost ($)
$2,267.67
4
Days

2000
3

2
1000

0
0
Survivor Dead
Survivors Dead
 Results- Secondary Outcomes
Mortality For Various Critical Care Interventions Among DNR Patients
P value
Type of Aggressive Care

Vasopressor Use 12.79 (5.65-29.98) <0.001

Non-Invasive Ventilation 2.56 (1.61-4.06) <0.001

Mechanical Ventilation 19.38 (8.74-42.96) <0.001

Renal Replacement Therapy 3.68 (1.31-10.34) 0.009

Intensive Care Unit 7.34 (4.49-11.98) <0.001

-10 0 10 20 30 40 50
Odds Ratio For Mortality
 Discussion
• A minor fraction (4%) of patients have DNR orders on admission
• 12x more likely to die during hospitalization, especially if they
required aggressive interventions
• Hospice involvement; early goals-of-care discussions 1, 2
• Resource allocation
• DNR does not lead to cessation of appropriate medical care 4
however, aim is to avoid non-beneficial interventions 3
1 Khandelwal, N., Kross, E. K., Engelberg, R. A., Coe, N. B., Long, A. C., & Curtis, J. R. (2015). Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization. Critical
Care Medicine, 43(5), 1102-1111. doi:10.1097/ccm.0000000000000852
2 Campbell, M. L., & Guzman, J. A. (2003). Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU. Chest, 123(1), 266-271. doi:10.1378/chest.123.1.266
3 Saha, D., Moreno, C., Csete, M., et. al. (2016). Outcomes of Patients Who Have Do Not Resuscitate Status prior to Being Admitted to an Intensive Care Unit. Scientifica, 2016, 1-3.

doi:10.1155/2016/1513946
4 Azad, A. A., Siow, S., & Tafreshi, A. (2014). Discharge Patterns, Survival Outcomes, and Changes in Clinical Management of Hospitalized Adult Patients with Cancer with a Do-Not-Resuscitate Order.

Journal of Palliative Medicine, 17(7), 776-781. doi:10.1089/jpm.2013.0554

 Case #2
• 82 y/o woman
• Contracted, advanced Parkinsons Dementia, recurrent falls, minimally
verbal, dependent on all ADLs/IADLs
• Husband wheelchair-bound, primary caretaker of patient
• ICU consulted subdural hematoma
• Goals of care discussion PMD with family— “all possible measures”
 Case #2
• 82 y/o woman
• Contracted, advanced Parkinsons Dementia, recurrent falls, minimally
verbal, dependent on all ADLs/IADLs
• Husband wheelchair-bound, primary caretaker of patient
• ICU consulted subdural hematoma
• Goals of care discussion PMD with family— “all possible measures”
• No surgery was needed; discharged home per family request
• Returns with another fall—CTH demonstrates SDH with large midline shift,
herniation
• Postsurgery- still not following commands, confused, minimally verbal
• Complicated by UTI, Asp PNA
 Study Limitations
• Single center study
• Small sample size
• Heterogeneity of admitting diagnoses
• State legislation and physician comfort in end of life care
 Future Directions

• Impact of POLST form

• Larger cohort, multicenter
study
• Recognize barriers to
improve care at end of life
 Thank You
Medical Humanities Mentor: Dr. Phyllis DeJesse
Research Mentor/Study Principle Investigator: Dr. Nirav Mistry

Our Research Team

Department of Medicine: Shanojan Thiyagalingam MD, Nikhil R. Shah BA, Jordan Resnick MD, Saad Amin MD, Saima
Manzoor MD

Division of Critical Care: Nirav Mistry MD, Kristin Fless MD, Fariborz Rezai MD, Vagram Ovnanian MD, Paul Yodice MD