title: Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest.
abstract: OBJECTIVE
  After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.
  
  
  OBJECTIVE
  To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis.
  
  
  METHODS
  Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (ie, without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined.
  
  
  METHODS
  Do-not-resuscitate orders within 12 hours of ROSC.
  
  
  METHODS
  Likelihood of favorable neurological survival.
  
  
  RESULTS
  Overall, 5944 (22.6% [95% CI, 22.1%-23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P < .05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (P for both trends <.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI, 29.9%-31.1%]) than it was for those with DNR orders (1.8% [95% CI, 1.6%-2.0%]). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis.
  
  
  CONCLUSIONS
  Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including those with the best prognosis.
authors.affiliation: Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Fendler
authors.affiliation: Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.affiliation: Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor.
authors.forename: Lena M
authors.initials: LM
authors.lastname: Chen
authors.affiliation: Department of Emergency Medicine, University of Colorado School of Medicine, Denver.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Perman
authors.affiliation: Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Chan
mesh_terms: D000367:Age Factors; D000368:Aged; D003326:Coronary Circulation / Q000502:physiology; D005260:Female; D006323:Heart Arrest / Q000401:mortality* / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011336:Probability; D011379:Prognosis; D020127:Recovery of Function; D012151:Resuscitation / Q000706:statistics & numerical data*; D016414:Resuscitation Orders; D017741:Survivors