DNR Status and Hospital Mortality Measures Postmyocardial Infarction: Differentiating Preventable From Unpreventable
Benjamin D Pollock1, Annette M Danks2, Razvan M Chirila3
1Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL (B.D.P.).
Circulation. Population Health and Outcomes
|July 30, 2026
Summary
Publicly reported acute myocardial infarction (AMI) mortality rates may be inaccurate. Including patients with do-not-resuscitate (DNR) orders or palliative care inflates these metrics, masking preventable deaths.
Area of Science:
- Cardiology
- Healthcare Quality
- Palliative Care
Background:
- Publicly reported 30-day acute myocardial infarction (AMI) mortality rates are used to benchmark hospital performance.
- These metrics may lack validity when including patients with do-not-resuscitate (DNR) orders or those receiving palliative care, for whom mortality may be expected.
Purpose of the Study:
- To assess the impact of do-not-resuscitate (DNR) status and palliative care on 30-day AMI mortality rates.
- To evaluate the validity of current hospital performance measures for AMI.
Main Methods:
- Analysis of the national Medicare Inpatient Standard Analytic File for 30-day AMI mortality rates stratified by DNR status and palliative care.
- Retrospective chart review of AMI mortalities at an academic medical center (2019-2025).
- Application of Global Registry of Acute Coronary Events and Palliative Performance Scale scores to identify unpreventable deaths.
Main Results:
- Higher 30-day mortality rates were observed in patients with present-on-admission DNR (43.1%) and postadmission DNR (72.1%) compared to those without DNRs (10.4%).
- Patients receiving palliative care had a 76.9% mortality rate.
- Unpreventable death criteria were met by 33% of mortalities in a single-center review.
Conclusions:
- Inclusion of high-acuity, end-of-life patients in AMI mortality metrics may undermine their validity.
- Excluding DNR or palliative care cases from performance measures should be explored to better identify opportunities for reducing preventable deaths.
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