Link between decisions regarding resuscitation and preferences for quality over length of life with heart failure.
OBJECTIVE
Survival preferences, ascertained from time-trade-off utilities, have not been studied in heart failure patients who designate a 'do not resuscitate' (DNR) status. Therefore, the aim of this study was to determine the association of heart failure patients' resuscitation preferences with survival preferences and mortality in the ESCAPE trial.


RESULTS
We analysed the association of resuscitation orders at 1 month with time-trade-off utilities and 6-month mortality. There were 26 and 349 patients with a DNR order and Full Code order, respectively. DNR patients were older, had more coronary artery disease, hypertension, renal impairment, and poorer exercise capacity than Full Code patients. DNR patients also experienced longer hospitalization and higher 6-month mortality. In multivariate analysis, DNR preference was associated with 10-fold higher odds of willingness to trade survival time (lower time-trade-off utility) in favour of improved quality of life [odds ratio 10.33, 95% confidence interval (CI) 1.65-64.80]. DNR preference was the best predictor of mortality (χ(2) 26.12, P < 0.0001, hazard ratio 6.88, 95% CI 3.28-14.41), despite adjustment for known predictors including brain natriuretic peptide.


CONCLUSIONS
Heart failure patients' requests to forego resuscitation may signify more than simply 'what-if' directives for emergency care. DNR decisions may reflect preferences for intervention to enhance quality rather than prolong survival, which is particularly important as these patients have high early mortality.
Phoenix VA Health Care System, 650 E. Indian School Road, Phoenix, AZ 85012, USA. Sandesh.Dev@va.gov
Sandesh
S
Dev
Robert M
RM
Clare
G Michael
GM
Felker
Mona
M
Fiuzat
Lynne
L
Warner Stevenson
Christopher M
CM
O'Connor
D000368:Aged; D015897:Comorbidity; D003657:Decision Making; D005260:Female; D054624:Health Status Disparities; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000523:psychology; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016134:Organizational Policy; D011379:Prognosis; D016016:Proportional Hazards Models; D011788:Quality of Life / Q000523:psychology; D019057:Quality-Adjusted Life Years; D016414:Resuscitation Orders / Q000941:ethics / Q000331:legislation & jurisprudence / Q000523:psychology; D013997:Time Factors