alignment of dnr status with patients’ likelihood of favorable neurological survival after in-...
TRANSCRIPT
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