Do-not-attempt-resuscitation order rates compared for heart failure, other hospital conditions

Rates of do-not-attempt-resuscitation (DNAR) orders were low overall among patients hospitalized for heart failure, chronic obstructive pulmonary disease (COPD), pneumonia, or acute myocardial infarction (MI), and for the former two conditions, patients at hospitals caring for more Black patients were less likely to have DNAR orders in place, a recent study found.

Researchers used the California State Inpatient Dataset to perform a retrospective study of all adult hospitalizations for heart failure, acute MI, COPD, and pneumonia from 2010 to 2016 and identified factors associated with DNAR orders for each condition. To determine racial variation, hospitals were divided into quintiles based on the proportion of Black patients who received care there. The results of the study were published Nov. 16 by the Journal of the American Heart Association.

A total of 399,816 heart failure hospitalizations, 190,802 acute MI hospitalizations, 192,640 COPD hospitalizations, and 269,262 pneumonia hospitalizations were included in the study. DNAR orders were most common in patients hospitalized for heart failure (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and acute MI (7.1%). Prevalence of DNAR orders did not change over the study period. DNAR orders were more common for all conditions in elderly patients, women, and White patients. Significant site-level variation was seen across the 472 hospitals, and hospitals that cared for a higher proportion of Black patients were less likely to have heart failure or COPD patients hospitalized with a DNAR in place. Chronic terminal conditions, such as dementia and malignancy, were strongly associated with DNAR orders for acute MI and pneumonia hospitalizations.

The authors concluded that rates of DNAR orders in patients with heart failure remain low, similar to those in patients with pneumonia but higher than those with acute MI and COPD, and vary significantly by site. They noted that findings of racial disparities in DNAR orders for heart failure and COPD highlight geographic and racial disparities in end-of-life care. “Our findings provide a call to action for providers to address advanced care directives for patients with [heart failure] in a timely fashion,” the authors wrote. “Ideally, such discussions should be initiated in the outpatient setting and not during an acute hospitalization when decision-making capacity can be hampered. More important, such discussions should be considered standard of care.”