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Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity
Insights
Do-Not-Resuscitate Comfort Care (DNRCC) patients received less aggressive care, while DNR Comfort Care-Arrest (DNRCC-Arrest) patients maintained aggressive interventions. Both groups received increased comfort care, with no significant cost differences compared to non-DNR patients.
Area of Science:
- Medical Ethics
- Critical Care Medicine
- Health Policy
Background:
- Do-Not-Resuscitate (DNR) orders can lead to reduced medical care for patients.
- Ohio's 1998 DNR law established two protocols: DNR Comfort Care (DNRCC) and DNR Comfort Care-Arrest (DNRCC-Arrest).
- DNRCC patients receive only comfort care, while DNRCC-Arrest patients may receive aggressive interventions until arrest.
Purpose of the Study:
- To examine the medical care provided to patients under the two distinct DNR protocols (DNRCC and DNRCC-Arrest).
- To compare medical care and costs between DNRCC, DNRCC-Arrest, and non-DNR patients.
Main Methods:
- Retrospective analysis of 2,051 non-DNR, 88 DNRCC, and 188 DNRCC-Arrest patients from August 2002 to December 2005.
- Propensity score matching used to balance confounding variables between groups.
- Analysis included daily ICU and hospital costs, aggressive interventions, and comfort care measures.
Main Results:
- DNRCC patients received significantly fewer aggressive interventions and more comfort care post-order.
- DNRCC-Arrest patients showed no significant decrease in aggressive interventions but increased comfort care post-order.
- No significant differences in daily medical costs were observed between DNRCC/DNRCC-Arrest and non-DNR patients.
Conclusions:
- Clearer indications for DNR protocols influence healthcare professionals to provide care aligned with patient/surrogate decisions.
- The distinction between DNRCC and DNRCC-Arrest protocols allows for tailored medical care, avoiding blanket reductions in interventions.
- This approach respects patient autonomy while ensuring appropriate medical management.
Background:
Do-Not-Resuscitate (DNR) patients tend to receive less medical care after the order is written. To provide a clearer approach, the Ohio Department of Health adopted the Do-Not-Resuscitate law in 1998, indicating two distinct protocols of DNR orders that allow DNR patients to choose the medical care: DNR Comfort Care (DNRCC), implying DNRCC patients receive only comfort care after the order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), implying that DNRCC-Arrest patients are eligible to receive aggressive interventions until cardiac or respiratory arrest. The aim of this study was to examine the medical care provided to patients with these two distinct protocols of DNR orders.
Methods:
Data were collected from August 2002 to December 2005 at a medical intensive care unit in a university-affiliated teaching hospital. In total, 188 DNRCC-Arrest patients, 88 DNRCC patients, and 2,051 non-DNR patients were included. Propensity score matching using multivariate logistic regression was used to balance the confounding variables between the 188 DNRCC-Arrest and 2,051 non-DNR patients, and between the 88 DNRCC and 2,051 non-DNR patients. The daily cost of intensive care unit (ICU) stay, the daily cost of hospital stay, the daily discretionary cost of ICU stay, six aggressive interventions, and three comfort care measures were used to indicate the medical care patients received. The association of each continuous variable and categorical variable with having a DNR order written was analyzed using Student's t-test and the χ2 test, respectively. The six aggressive interventions and three comfort care measures performed before and after the order was initiated were compared using McNemar's test.
Results:
DNRCC patients received significantly fewer aggressive interventions and more comfort care after the order was initiated. By contrast, for DNRCC-Arrest patients, the six aggressive interventions provided were not significantly decreased, but the three comfort care measures were significantly increased after the order was initiated. In addition, the three medical costs were not significantly different between DNRCC and non-DNR patients, or between DNRCC-Arrest and non-DNR patients.
Conclusions:
When medical care provided to DNR patients is clearly indicated, healthcare professionals will provide the medical care determined by patient/surrogate decision-makers and healthcare professionals, rather than blindly decreasing medical care.
