title: The impact of early do not resuscitate (DNR) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest.
abstract: OBJECTIVE
  Among patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) and admitted to California hospitals, we examined how the placement of a do not resuscitate (DNR) order in the first 24h after admission was associated with patient care, procedures and inhospital survival. We further analyzed hospital and patient demographic factors associated with early DNR placement among patients admitted following OHCA.
  
  
  METHODS
  We identified post-OHCA patients from a statewide California database of hospital admissions from 2002 to 2010. Documentation of patient and hospital demographics, hospital interventions, and patient outcome were analyzed by descriptive statistics and multiple regression models to calculate odds ratios and 95% confidence intervals.
  
  
  RESULTS
  Of 5212 patients admitted to California hospitals after resuscitation from OHCA, 1692 (32.5%) had a DNR order placed in the first 24h after admission. These patients had decreased frequency of cardiac catheterization (1.1% vs. 4.3%), blood transfusion (7.6% vs. 11.2%), ICD placement (0.1% vs. 1.1%), and survival to discharge (5.2% vs. 21.6%, all p-values<0.0001). There was wide intrahospital variability and significant racial differences in the adjusted odds of early DNR orders (Asian, OR 0.67, 95% CI 0.48-0.95; Black, OR 0.49, 95% CI 0.35-0.69).
  
  
  CONCLUSIONS
  Early DNR placement is associated with a decrease in potentially critical hospital interventions, procedures, and survival to discharge, and wide variability in practice patterns between hospitals. In the absence of prior patient wishes, DNR placement within 24h may be premature given the lack of early prognostic indicators after OHCA.
authors.affiliation: Oregon Health & Science University, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA. richader@ohsu.edu
authors.forename: Derek K
authors.initials: DK
authors.lastname: Richardson
authors.forename: Dana
authors.initials: D
authors.lastname: Zive
authors.forename: Mohamud
authors.initials: M
authors.lastname: Daya
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
mesh_terms: D001803:Blood Transfusion / Q000706:statistics & numerical data; D002140:California; D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D016887:Cardiopulmonary Resuscitation; D015331:Cohort Studies; D016208:Databases, Factual; D017147:Defibrillators, Implantable / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D058687:Out-of-Hospital Cardiac Arrest / Q000453:epidemiology / Q000628:therapy*; D010138:Pacemaker, Artificial / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D044469:Racial Groups / Q000706:statistics & numerical data; D016414:Resuscitation Orders; D012189:Retrospective Studies; D015607:Stents / Q000706:statistics & numerical data