Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic

Area of Science:

• Medical Ethics
• Health Disparities
• Critical Care Medicine

Background:

• Unilateral do-not-resuscitate (UDNR) orders bypass patient or surrogate consent, relying solely on clinician judgment.
• The COVID-19 pandemic presented unique challenges in end-of-life care decision-making.

Purpose of the Study:

• To assess the utilization patterns of UDNR orders during the COVID-19 pandemic.
• To identify patient populations disproportionately affected by UDNR orders.

Main Methods:

• A retrospective cross-sectional study analyzed UDNR use in two academic medical centers from April 2020 to April 2021.
• Inclusion criteria focused on ICU patients receiving vasopressors or inotropes, indicating high illness severity.

Main Results:

• UDNR orders were placed in 3% of 1,473 eligible patients.
• Higher rates of UDNR orders were observed in primary Spanish-speaking patients (10%), Hispanic/Latinx patients (7%), and COVID-19 positive patients (9%).
• Multivariable analysis revealed that Black race (aOR 2.5) and primary Spanish language (aOR 4.4) were associated with increased odds of UDNR, with language barriers remaining significant after adjusting for illness severity (aOR 2.8).

Conclusions:

• UDNR orders were disproportionately used in primary Spanish-speaking patients during the COVID-19 pandemic.
• Communication barriers may contribute to these disparities.
• Further research and interventions are needed to address potential inequities in UDNR order implementation.