Associations between the use of do-not-resuscitate orders and length of stay in patients with stroke.
OBJECTIVE
The study sought to describe the association between do-not-resuscitate (DNR) orders and length of hospital stay (LOS), and how the association varies according to in-hospital mortality, timing of the DNR order, and admission severity of illness.


METHODS
The authors conducted a retrospective cohort analysis involving standardized review of patients' medical records. The study was performed at 30 acute care hospitals in a large metropolitan area. The authors studied the data of 13,337 consecutive patients with a primary diagnosis of stroke discharged in 1991 through 1994.


RESULTS
Do-not-resuscitate orders were written for 22% (n = 2,898) of the sample. In all patients, mean LOS was longer in patients with DNR orders than in patients without orders (12.0 versus 9.5 days; P < 0.001). A series of Cox regression analyses were performed to adjust LOS for admission severity of illness and other covariates. In analyses of patients discharged alive (n = 12,011), LOS was similar in patients with DNR orders written on days 1 to 2 compared with patients without DNR orders. However, LOS was longer in patients with DNR orders written on days 3 to 7 (Hazard Ratio [HR], 1.59; 95% CI, 1.43-1.77) and on day 8 or later (HR, 2.72; 95% CI, 2.34-3.16). In analyses of patients who died (n = 1,326), LOS was shorter for patients with DNR orders written on days 1 and 2 (HR, 0.59; 95% CI, 0.49-0.71) than for patients without DNR orders but was longer among patients with DNR orders written on day 8 or later (HR, 2.58; 95% CI, 2.06-3.22). In analyses stratified by admission severity, the relative effect of a DNR order tended to be less in patients with higher severity.


CONCLUSIONS
The relationship between DNR orders and LOS is complex and varies according to in-hospital mortality, the timing of the DNR order, and admission severity of illness. These findings highlight the importance of explicitly accounting for such factors in studies evaluating the implications of DNR orders on the costs of hospital care.
Shepardson
L B
LB
Cleveland VA Medical Center, Department of Epidemiology, Case Western Reserve University School of Medicine, OH, USA.
Justice
A C
AC
Harper
D L
DL
Rosenthal
G E
GE
D000368:Aged; D000369:Aged, 80 and over; D002561:Cerebrovascular Disorders / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006786:Hospitals, Urban; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D009820:Ohio; D016016:Proportional Hazards Models; D016414:Resuscitation Orders; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors