Canadian Journal of Anesthesia

, Volume 51, Issue 10, pp 1034–1041

DNR directives are established early in mechanically ventilated intensive care unit patients

  • Tasnim Sinuff
  • Deborah J. Cook
  • Graeme M. Rocker
  • Lauren E. Griffith
  • Stephen D. Walter
  • Malcolm M. Fisher
  • Peter M. Dodek
  • Peter Sjokvist
  • Ellen McDonald
  • John C. Marshall
  • Peter A. Kraus
  • Mitchell M. Levy
  • Neil M. Lazar
  • Gordon H. Guyatt
  • Level of Care Study Investigators
  • Canadian Critical Care Trials Group
Neuroanesthesia and Intensive Care

Abstract

Purpose

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

Methods

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

Results

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74yr(HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3–2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4–2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7–33.6)], 10 to 40% [(HR 5.0, 2.3–11.2), 41 to 60% (HR 4.0, 1.8–9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6–9.4) or partial advanced life support (HR 3.2, 2.2–4.6) compared to full measures].

Conclusion

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.

Les directives PDR sont établies tôt chez les patients sous ventilation mécanique a l’unité des soins intensifs

Résumé

Objectif

Le choix des objectifs de traitement à l’unité des soins intensifs (USI) comprend souvent des décisions concernant la réanimation. Notre but était d’étudier le taux d’ordonnance «pas de réanimation» (PDR), les déterminants et les conséquences de ces directives pour tes patients ventiiés mécaniquement.

Méthode

Lors d’une étude par observation muiticentrique, nous avons indus des adultes pour qui la directive PDR avait été émise au cours des 24 premières heures de présence à l’USI et qui étaient sous ventiiation mécanique depuis au moins 48 h. Nous avons déterminé te taux de directives PDR étabiies et ies facteurs qui y sont associés.

Résultats

Parmi 765 patients, il y a eu des directives PDR dans 231 (30,2 %) des cas; 143 (62,1 %) d’entre elles à l’intérieur de la première semaine. Les facteurs indépendamment associés à la directive PDR ont été : l’âge du patient [ = 75 ans (risque relatif [RR] de 2,3, intervalle de confiance de 95 % 1,5-3,4], 65 à 74 ans (RR de 1,8, 1,2–2,7), 50 à 64 ans (RR de 1,4, 1,0-2,2) par rapport à < 50 ans) ; le diagnostic médical plutôt que chirurgical (RR de 1,8, 1,3-2,5) ; le score de défaillance multiviscérale (RR de 1,7 pour chaque palier de cinq points, 1,4–2,0); la prédiction de survie à l’USI selon le médecin [< 10 % (RR de 15,0, 6,7- 33,6)], 10 à 40 % [(RR de 5,0, 2,3–11,2), 41 à 60% (RRde 4,0, 1,8–9,0) par rapport à > 90%] ; la perception du médecin de la préférence du patient face aux limites du maintien de la vie (par de maintien poussé [(RR de 5,8, 3,6–9,4) ou maintien poussé partiel (RR de 3,2, 2,2–4,6) comparé aux pleines mesures].

Conclusion

Des directives PDR sont établies tôt pendant le séjour à l’USI, 24 h ou plus après l’admission, chez un tiers des patients ventilés mécaniquement. Les prédicteurs les plus puissants de directives PDR sont la prédiction du médecin d’une faible probabilité de survie, la perception du médecin de la préférence du patient face à la limite du maintien de la vie, la dysfonction organique, le diagnostic médical et l’âge.

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Copyright information

© Canadian Anesthesiologists 2004

Authors and Affiliations

  • Tasnim Sinuff
    • 1
  • Deborah J. Cook
    • 1
    • 2
  • Graeme M. Rocker
    • 3
  • Lauren E. Griffith
    • 2
  • Stephen D. Walter
    • 2
  • Malcolm M. Fisher
    • 4
  • Peter M. Dodek
    • 5
  • Peter Sjokvist
    • 6
  • Ellen McDonald
    • 2
  • John C. Marshall
    • 7
  • Peter A. Kraus
    • 1
  • Mitchell M. Levy
    • 8
  • Neil M. Lazar
    • 9
  • Gordon H. Guyatt
    • 1
    • 2
  • Level of Care Study Investigators
  • Canadian Critical Care Trials Group
  1. 1.Department of MedicineMcMaster UniversityHamiltonCanada
  2. 2.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  3. 3.Department of MedicineDalhousie UniversityHalifaxCanada
  4. 4.Intensive Therapy Unit, Royal North Shore HospitalUniversity of SydneySydneyAustralia
  5. 5.Program of Critical Care Medicine and Center for Health Evaluation and Outcome SciencesUniversity of British ColumbiaVancouverCanada
  6. 6.Department of Anesthesia and Intensive CareHuddinge UniversityStockholmSweden
  7. 7.Department of SurgeryUniversity of TorontoTorontoCanada
  8. 8.Department of MedicineBrown UniversityProvidenceUSA
  9. 9.Department of MedicineUniversity of Toronto and University Health NetworkTorontoCanada
  10. 10.Department of Medicine & Epidemiology and BiostatisticsMcMaster University Health Sciences CenterHamiltonCanada

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