title: Impact of early do-not-attempt-resuscitation orders on procedures and outcomes of severe sepsis.
abstract: Do-not-attempt-resuscitation (DNAR) orders are common in severe sepsis, but the impact on clinical care is not known. Our primary objective was to determine the impact of early DNAR orders on in-hospital mortality and performance of key interventional procedures among severe sepsis hospitalizations. Our secondary objective was to further investigate what patient characteristics within the sepsis DNAR population affected outcomes.
  
  
  
  Using the 2010-2011 California State Inpatient Dataset, we analyzed hospitalizations for adults admitted through the emergency department with severe sepsis. Our primary predictor was a DNAR order, and our outcomes were in-hospital mortality and performance of interventional procedures.
  
  
  
  Visits with early DNAR orders accounted for 20.3% of severe sepsis hospitalizations. An early DNAR order was a strong, independent predictor of higher in-hospital mortality (odds ratio [OR], 4.03; 95% confidence interval, 3.88-4.19) and lower performance of critical procedures: central venous line (OR, 0.70), mechanical ventilation (OR, 0.80), hemodialysis (OR, 0.61), and major operative procedure (OR, 0.46). Among those with early DNAR orders, older age and rural location were the strongest predictors for a lack of interventional procedures.
  
  
  
  Although DNAR orders are not synonymous with "do not treat," they may unintentionally limit aggressive treatment for severe sepsis patients, especially in older adults.
authors.affiliation: Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Case Western Reserve University School of Medicine, Cleveland, OH. Electronic address: nns12@case.edu.
authors.forename: Neza N
authors.initials: NN
authors.lastname: Sarkari
authors.affiliation: Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO. Electronic address: sarah.perman@ucdenver.edu.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Perman
authors.affiliation: Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO. Electronic address: adit.ginde@ucdenver.edu.
authors.forename: Adit A
authors.initials: AA
authors.lastname: Ginde
mesh_terms: D000293:Adolescent; D000328:Adult; D016223:Advance Directives; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002140:California; D002405:Catheterization, Central Venous / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012121:Respiration, Artificial / Q000706:statistics & numerical data*; D016414:Resuscitation Orders; D012424:Rural Population; D018805:Sepsis / Q000628:therapy*; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D013997:Time Factors; D055815:Young Adult
keywords: Advance directives; Hospital mortality; Medical futility; Procedures; Resuscitation orders; Sepsis