In-hospital cardiac arrest: factors in the decision not to resuscitate. The impact of an organized in-hospital emergency system.
OBJECTIVE
To identify factors associated with "do-not-resuscitate" (DNR) decisions in patients who suffer cardiac arrest.


METHODS
Hospital Pedro Hispano has an emergency system based on broad preset criteria of physiologic instability, which include airway compromise, bradypnea or tachypnea, bradycardia or tachycardia sustained hypotension, sudden loss of consciousness, decrease in the Glasgow coma scale, repeated and prolonged seizures, respiratory arrest and cardiac arrest. This retrospective study is based on data collected between January 2002 and August 2006. Variables studied included demographic characteristics (age and gender), comorbidities (neurological, cardiac and chronic renal disease, AIDS and cancer, classified as mild, moderate or severe), cardiac arrest variables (measures initiated before arrival of the medical emergency team [MET], including none, venous line, intravenous medication, endotracheal tube, manual ventilation, chest compressions, and external pacemaker; cause of cardiac arrest, classified as cardiac or noncardiac; and initial rhythm of cardiac arrest as shockable or non-shockable). Comparisons were made between the group of patients in which cardiopulmonary resuscitation (CPR) was performed and the group in which CPR was not performed.


RESULTS
There were 649 MET calls, of which 227 were for cardiac arrest. In 91 of these patients CPR was not started or was stopped. Twenty-two (24%) of these patients had a DNR order in their clinical records, in 18 (20%) CPR was not started because it was considered futile, and in 47 (52%) CPR was stopped for the same reason. Age, cancer, and no measures having been initiated before arrival of the MET were significantly associated with the DNR decision.


CONCLUSIONS
This is the first study aimed at identifying factors associated with DNR decisions in a Portuguese hospital with an organized emergency system. DNR decisions were taken in 33% of cases of cardiac arrest. Advanced age, cancer, and no measures initiated before arrival of the MET were associated with the DNR decision. These findings need to be confirmed in larger studies and should be taken into account when taking DNR decisions.
Serviço de Cuidados Intensivos Médicos, Hospital Pedro Hispano, Matosinhos, Portugal.
Antonio
A
Mendes
Flávia
F
Carvalho
Cláudia
C
Dias
Cristina
C
Granja
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000592:standards*; D005260:Female; D006323:Heart Arrest / Q000628:therapy*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D016414:Resuscitation Orders; D012189:Retrospective Studies