title: DNR directives are established early in mechanically ventilated intensive care unit patients.
abstract: OBJECTIVE
  Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.
  
  
  METHODS
  In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.
  
  
  RESULTS
  Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> or = 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5-3.4], 65 to 74 yr (HR 1.8, 1.2-2.7), 50 to 64 yr (HR 1.4, 1.0-2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3-2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4-2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7-33.6)], 10 to 40% [(HR 5.0, 2.3-11.2), 41 to 60% (HR 4.0, 1.8-9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6-9.4) or partial advanced life support (HR 3.2, 2.2-4.6) compared to full measures].
  
  
  CONCLUSIONS
  One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.
authors.affiliation: Department of Medicine, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
authors.forename: Tasnim
authors.initials: T
authors.lastname: Sinuff
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cook
authors.forename: Graeme M
authors.initials: GM
authors.lastname: Rocker
authors.forename: Lauren E
authors.initials: LE
authors.lastname: Griffith
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Walter
authors.forename: Malcolm M
authors.initials: MM
authors.lastname: Fisher
authors.forename: Peter M
authors.initials: PM
authors.lastname: Dodek
authors.forename: Peter
authors.initials: P
authors.lastname: Sjokvist
authors.forename: Ellen
authors.initials: E
authors.lastname: McDonald
authors.forename: John C
authors.initials: JC
authors.lastname: Marshall
authors.forename: Peter A
authors.initials: PA
authors.lastname: Kraus
authors.forename: Mitchell M
authors.initials: MM
authors.lastname: Levy
authors.forename: Neil M
authors.initials: NM
authors.lastname: Lazar
authors.forename: Gordon H
authors.initials: GH
authors.lastname: Guyatt
mesh_terms: D018806:APACHE; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D001315:Australia; D002170:Canada; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012121:Respiration, Artificial / Q000706:statistics & numerical data*; D016414:Resuscitation Orders; D013548:Sweden; D013997:Time Factors; D014481:United States; D028761:Withholding Treatment / Q000706:statistics & numerical data