Open Access Research article

Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching

Yen-Yuan Chen12, Nahida H Gordon3, Alfred F Connors4, Allan Garland5, Shan-Chwen Chang67* and Stuart J Youngner3

Author Affiliations

1 Department of Social Medicine, National Taiwan University College of Medicine, No. 1, Rd. Ren-Ai sec. 1, Taipei 10051, Taiwan

2 Department of Medical Education, National Taiwan University Hospital, No. 7, Rd. Chong-Shan S., Taipei 10002, Taiwan

3 Department of Bioethics, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland 44106-4976, OH, USA

4 Department of Medicine, Case Western Reserve University School of Medicine at MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland 44109, OH, USA

5 Department of Medicine and Community Health Services, University of Manitoba, 66 Chancellors Cir, Winnipeg R3T 2N2, Manitoba MB, Canada

6 Department of Internal Medicine, National Taiwan University College of Medicine, Address: No. 1, Rd. Ren-Ai sec. 1, Taipei 10051, Taiwan

7 Department of Internal Medicine, National Taiwan University Hospital, Address: No. 7, Rd. Chong-Shan S., Taipei 10002, Taiwan

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BMC Medicine 2014, 12:146  doi:10.1186/s12916-014-0146-x

Published: 29 August 2014

Abstract

Background

Do-Not-Resuscitate (DNR) patients tend to receive less medical care after the order is written. To provide a clearer approach, the Ohio Department of Health adopted the Do-Not-Resuscitate law in 1998, indicating two distinct protocols of DNR orders that allow DNR patients to choose the medical care: DNR Comfort Care (DNRCC), implying DNRCC patients receive only comfort care after the order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), implying that DNRCC-Arrest patients are eligible to receive aggressive interventions until cardiac or respiratory arrest. The aim of this study was to examine the medical care provided to patients with these two distinct protocols of DNR orders.

Methods

Data were collected from August 2002 to December 2005 at a medical intensive care unit in a university-affiliated teaching hospital. In total, 188 DNRCC-Arrest patients, 88 DNRCC patients, and 2,051 non-DNR patients were included. Propensity score matching using multivariate logistic regression was used to balance the confounding variables between the 188 DNRCC-Arrest and 2,051 non-DNR patients, and between the 88 DNRCC and 2,051 non-DNR patients. The daily cost of intensive care unit (ICU) stay, the daily cost of hospital stay, the daily discretionary cost of ICU stay, six aggressive interventions, and three comfort care measures were used to indicate the medical care patients received. The association of each continuous variable and categorical variable with having a DNR order written was analyzed using Student┬┐s t-test and the ?2 test, respectively. The six aggressive interventions and three comfort care measures performed before and after the order was initiated were compared using McNemar┬┐s test.

Results

DNRCC patients received significantly fewer aggressive interventions and more comfort care after the order was initiated. By contrast, for DNRCC-Arrest patients, the six aggressive interventions provided were not significantly decreased, but the three comfort care measures were significantly increased after the order was initiated. In addition, the three medical costs were not significantly different between DNRCC and non-DNR patients, or between DNRCC-Arrest and non-DNR patients.

Conclusions

When medical care provided to DNR patients is clearly indicated, healthcare professionals will provide the medical care determined by patient/surrogate decision-makers and healthcare professionals, rather than blindly decreasing medical care.

Keywords:
Medical care; Cardiopulmonary resuscitation; Do-Not-Resuscitate