The Impact of Signing Do-Not-Resuscitate Orders on the Use of Non-Beneficial Life-Sustaining Treatments for Intensive Care Unit Patients: A Retrospective Study
Abstract
:1. Introduction
Objective
2. Methods
2.1. Design
2.2. Sample and Setting
2.3. Ethical Considerations
2.4. Instruments
2.5. Data Collection and Analysis
3. Results
3.1. Patients’ Characteristics with Regard to Signing or Non-Signing of a DNR
3.2. Influence of DNR Signing and Timing on Predeath Resuscitation Practice
3.3. Signing the DNR for Withdrawing Life-Sustaining Treatments
4. Discussion
4.1. DNR Signing Ratio and Timing as an Ethical Dilemma
4.2. Illness Severity Assessment Had a Positive Effect on DNR Signing
4.3. Signing DNR Orders Effectively Reduces Resuscitation Practices before Death
4.4. DNR Signing Did Not Facilitate the Withdrawal of Life-Sustaining Treatments
4.5. Limitations of the Study
4.6. Suggestions
5. Conclusions
Application in Clinical Practice
6. Implications for Clinical Practice
- (1)
- Learn about the current state of life-sustaining therapies in the ICU under the national health insurance support.
- (2)
- Facilitate the patient’s understanding of the benefits of natural death after signing a DNR order in the ICU.
- (3)
- Facilitate learning with regard to the low withdrawal rate of non-beneficial life-sustaining treatments in the ICU.
- (4)
- Provide a reference for considering the timing of DNR decision-making and the discussion of “time-limited trials” for withdrawal from non-beneficial life-sustaining treatments.
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Variable | Total n = 386 | Non-DNR n = 67 | DNR n = 319 | p |
---|---|---|---|---|
Age | 65.6 ± 17.8 | 63.1 ± 18.8 | 66.2 ± 17.5 | 0.418 |
Number of ICU admissions in one year | 1.13 ± 0.49 | 1.15 ± 0.66 | 1.13 ± 0.44 | 0.788 |
Number of hospitalisations in one year | 3.02 ± 3.32 | 3.34 ± 3.63 | 2.95 ± 3.25 | 0.41 |
Number of emergency room visits in one year | 2.01 ± 2.39 | 1.76 ± 1.84 | 2.07 ± 2.49 | 0.344 |
Length of the last stay in ICU (days) | 7.2 ± 9.16 | 4.79 ± 7.85 | 7.7 ± 9.34 | 0.018 * |
Sex | 0.266 | |||
Female | 144 (37.3%) | 29 (20.1%) | 115 (79.9%) | |
Male | 242 (62.7%) | 38 (15.7%) | 204 (84.3%) | |
Marital status | 0.016 * | |||
Married | 249 (64.5%) | 47 (70.1%) | 202 (63.3%) | |
Unmarried | 56 (14.5%) | 14 (20.9%) | 42 (13.2%) | |
Widowed/Divorced | 81 (21%) | 6 (9%) | 75 (23.5%) | |
Employed | 0.315 | |||
Yes | 135 (34.9%) | 27 (40.3%) | 108 (33.9%) | |
No | 251 (65%) | 40 (59.7%) | 211 (66.1%) | |
Religion | 0.781 | |||
None | 151 (39.1%) | 23 (33.4%) | 128 (40.1%) | |
Buddhism | 139 (36%) | 26 (39.4%) | 113 (35.4%) | |
Taoism | 74 (19.2%) | 16 (24.2%) | 58 (18.2%) | |
Others | 22 (5.7%) | 2 (3%) | 20 (6.3%) | |
Living style | 0.251 | |||
Living with family | 343 (88.9%) | 60 (89.6%) | 283 (88.7%) | |
Living alone | 23 (6%) | 2 (3%) | 21 (6.6%) | |
Living in a nursing home | 20 (5.2%) | 5 (7.4%) | 15 (4.7%) | |
Specialty | 0.231 | |||
Haematology and Oncology | 109 (28.2%) | 21 (31.3%) | 88 (27.6%) | |
Gastroenterology | 79 (20.5%) | 10 (14.9%) | 69 (21.6%) | |
Infectious diseases | 63 (16.3%) | 15 (22.4%) | 48 (15%) | |
Nephrology | 37 (9.6%) | 3 (4.5%) | 34 (10.6%) | |
Others | 98 (25.4%) | 18 (26.9%) | 80 (25.1%) | |
Palliative care consultation | 101 (26.2%) | 3 (4.5%) | 98 (30.7%) | <0.001 *** |
Death place | 0.057 | |||
Died in ICU | 294 (76.2%) | 45 (67.2%) | 249 (78.1%) | |
Predeath discharged | 92 (23.8%) | 22 (32.8%) | 70 (21.9%) |
Items | Total n = 386 | Non-DNR n = 67 | DNR n = 319 | p |
---|---|---|---|---|
Worst physical conditions within 24 h of ICU admission | ||||
GCS score | 7.8 ± 3.9 | 7.5 ± 4.1 | 7.9 ± 3.9 | 0.425 |
SAPS II score | 73 ± 26 | 66.6 ± 28.2 | 74.4 ± 25.4 | 0.028 * |
APACHE II score | 29.9 ± 9.2 | 27.5 ± 10.6 | 30.4 ± 8.8 | 0.037 * |
Care needs for ICU admission | 0.996 | |||
Respiratory failure | 266 (68.9%) | 47 (70.1%) | 219 (68.7%) | |
Severe septic shock | 49 (12.7%) | 9 (13.4%) | 40 (12.5%) | |
Massive haemorrhage | 14 (3.6%) | 2 (3%) | 12 (3.8%) | |
Post-resuscitation | 30 (7.8%) | 5 (7.5%) | 25 (7.8%) | |
Diabetic ketoacidosis | 1 (0.3%) | 0 (0%) | 1 (0.3%) | |
Severe heart failure and acute pulmonary oedema | 8 (2.1%) | 1 (1.5%) | 7 (2.2%) | |
Drug toxicity with organ failure | 3 (0.8%) | 0 | 3 (0.9%) | |
Electrolyte imbalance of body fluids associated with renal failure | 4 (1%) | 1 (1.5%) | 3 (0.9%) | |
Others | 11 (2.8%) | 2 (3%) | 9 (2.8%) | |
Comfort care | ||||
Sedatives | 166 (43%) | 25 (37.3%) | 141 (44.2%) | 0.301 |
Muscle relaxants | 68 (17.6%) | 9 (13.4%) | 59 (18.5%) | 0.323 |
Analgesics | 173 (44.8%) | 20 (29.9%) | 153 (48%) | 0.007 ** |
Vascular line | ||||
An intra-arterial catheter (A-line) | 367 (95.1%) | 63 (94%) | 304 (95.3%) | 0.663 |
Central venous catheter (CVC) | 277 (71.7%) | 43 (64.2%) | 234 (73.4%) | 0.129 |
Item | Non-DNR n = 67 | DNR n = 319 | p | Time of DNR Signed | Resuscitations after DNR n = 75 | ||
---|---|---|---|---|---|---|---|
Before ICU Admission n = 26 | Within 24 h of ICU Admission n = 105 | 48 h after ICU Admission n = 188 | |||||
Chest compressions | 28 (41.8%) | 15 (4.7%) | <0.001 *** | 1 (3.8%) | 6 (5.7%) | 8 (4.3%) | 4 (5.3%) |
Electric shock | 8 (11.9%) | 4 (1.3%) | <0.001 *** | 1 (3.8%) | 2 (1.9%) | 1 (0.5%) | 1 (1.3%) |
Cardiotonic drugs injection | 36 (53.7%) | 83 (26%) | <0.001 *** | 9 (34.6%) | 37 (35.2%) | 37 (19.7%) | 73 (97.3%) |
Total n = 386 | Non-DNR n = 67 | DNR n = 319 | p | Withdrawal after DNR n = 319 | |
---|---|---|---|---|---|
Endotracheal tube & ventilator (ET) | 363 (94%) | 64 (95.5%) | 299 (93.7%) | 0.355 | 20 (6.27%) |
Vasopressors | 344 (89.1%) | 64 (95.5%) | 280 (87.8%) | 0.064 | 4 (1.25%) |
ECMO | 18 (4.7%) | 4 (6%) | 14 (4.4%) | 0.577 | 2 (0.63%) |
Continuous venovenous haemofiltration (CVVH) | 126 (32.6%) | 15 (22.4%) | 111 (34.8%) | 0.049 * | 2 (0.63%) |
Haemodialysis | 37 (9.6%) | 5 (7.5%) | 32 (10%) | 0.516 | 0 |
Antibiotics | 372 (96.4%) | 61 (91%) | 311 (97.5%) | 0.01 * | 0 |
Blood transfusion | 281 (72.8%) | 44 (65.7%) | 237 (74.3%) | 0.149 | 0 |
Intra-aortic balloon pump (IABP) | 4 (1%) | 2 (3%) | 2 (0.6%) | 0.083 | 1 (0.31%) |
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Shiu, S.-S.; Lee, T.-T.; Yeh, M.-C.; Chen, Y.-C.; Huang, S.-H. The Impact of Signing Do-Not-Resuscitate Orders on the Use of Non-Beneficial Life-Sustaining Treatments for Intensive Care Unit Patients: A Retrospective Study. Int. J. Environ. Res. Public Health 2022, 19, 9521. https://doi.org/10.3390/ijerph19159521
Shiu S-S, Lee T-T, Yeh M-C, Chen Y-C, Huang S-H. The Impact of Signing Do-Not-Resuscitate Orders on the Use of Non-Beneficial Life-Sustaining Treatments for Intensive Care Unit Patients: A Retrospective Study. International Journal of Environmental Research and Public Health. 2022; 19(15):9521. https://doi.org/10.3390/ijerph19159521
Chicago/Turabian StyleShiu, Shang-Sin, Ting-Ting Lee, Ming-Chen Yeh, Yu-Chi Chen, and Shu-He Huang. 2022. "The Impact of Signing Do-Not-Resuscitate Orders on the Use of Non-Beneficial Life-Sustaining Treatments for Intensive Care Unit Patients: A Retrospective Study" International Journal of Environmental Research and Public Health 19, no. 15: 9521. https://doi.org/10.3390/ijerph19159521