Patient autonomy to place do-not-resuscitate order low in COVID-19 hospitalization
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Among high-risk patients, discussion of do-not-resuscitate orders should take place prior to hospitalization, as only 10% of patients possessed the autonomy to do so after admission for severe COVID-19, a speaker reported.
“CPR, as it was initially conceived, was reserved for patients in cardiac arrest who are in a good state of health prior to the event. It has since evolved into the standard of care for cardiac arrest in all patients,” Johnathan Kirupakaran, DO, a chief resident in the department of medicine at Woodhull Medical Center in Brooklyn, New York, said during a presentation at the American Society for Preventive Cardiology Congress on CVD Prevention. “Survival rates for in-hospital CPR, however, remain very poor. Rates are estimated at less than 20% and survival to discharge near 0%. Variables that may affect CPR survival ... notably age, race, sepsis and pneumonia, are considerable in the context of COVID-19. [In two publications], the survival rate for in-hospital cardiac arrest among patients with COVID-19 was less than 11%.”
Researchers at Woodhull Medical and Mental Health Center evaluated demographic, clinical and outcome data of 520 people admitted for COVID-19 between March 20 and May 5, 2020. Among these patients, 115 had documented do-not-resuscitate (DNR) orders. Outcomes of interest included survival to discharge, DNR order placed within 24 hours of admission and identity of DNR decision maker.
Among patients with DNR orders hospitalized for COVID-19, approximately 53% were men, 53% were Hispanic and the median age was 77 years.
By comparison, those without DNR orders were predominantly men (61%) with a median age of 59 years. Like the DNR group, most of these patients were Hispanic (53%).
Researchers found that among patients with DNR orders, 29.6% were placed prior to COVID-19 hospitalization or within 24 hours of admission.
Kirupakaran and colleagues also observed that 3.5% of the DNR orders were placed relatively late in the patients’ clinical course, following cardiac arrest with performed CPR and return of spontaneous circulation.
Overall, 10.4% of patients directly placed their own DNR orders while 83.5% of orders were placed by a surrogate or health care proxy.
Placement of DNR orders among patients hospitalized with COVID-19 was associated with greater risk for in-hospital mortality compared with the non-DNR group (OR = 17.346; 95% CI, 9.9805-30.145; P < .001).
Moreover, 15.7% of patients with DNR orders survived to discharge.
“CPR is very much an invasive, traumatic cardiovascular intervention. The ethical considerations for CPR are important, particularly in the setting of an aging American population,” Kirupakaran said. “Appropriate education given to patients directly prior to a critical event is crucial to preserving patient autonomy and making sure that they are making the decision themselves. Education offered by health care workers on CPR outcomes remains largely variable; however, use of decision-making tools, such as the pre-arrest morbidity score may be used to help explain outcomes.
“Further research is required on the effect of education status and religious background on CPR education,” Kirupakaran said. “The other salient takeaway point from this project is the consideration for ethics as a major facet in preventive cardiology. While you work to prevent the onset of or worsening of disease, it is also pertinent to prevent undue harm of the treatments we provide.”
The presentation won third place in the Early Career Presentations competition.
References:
- Hayek SS, et al. BMJ. 2020;doi:10.1136/bmj.m3513.
- Thapa SB, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2020.4796.
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Kirupakaran J, et al. Early Career Research. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 23-25, 2021 (virtual meeting).
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