Background: Do-not-resuscitate (DNR) orders are intended to allow patients to forgo cardiopulmonary resuscitate (CPR) in the event of cardiac arrest. They are applied to cases of cardiac arrest, and they cannot be applied to any situation other than cardiac arrest. However, prior studies have shown that the presence of DNR orders led to changes in treatment and management strategy of hospitalized patients with cardiac diseases in the USA. This retrospective cohort study evaluated the effect of DNR status on the quality of clinical performance in patients with acute heart failure (AHF) in Japan. We also investigated the differences of characteristics, major comorbidities, and mortality of patients between in the presence and absence of DNR orders.
Methods: We conducted a retrospective cohort study of patients who were admitted to our hospital with a primary diagnosis of AHF between April 2013 and March 2015. Patient’s characteristics, DNR status, laboratory and echocardiography data as well as mortality were collected by retrospective chart review or telephone interviews in cases of data deficit. Three clinical performance measures were chosen according to American Heart Association recommendation; the assessment of cardiac function by echocardiography for all patients and the use of β blockers, angiotensin receptor blocking agents (ARBA) for patients of AHF with reduced ejection fraction (40% and less than 40%).
Results: The characteristics, comorbidities and outcomes based on the presence of DNR orders are presented in Table 1. About 30% of hospitalized patients had DNR orders on admission. The mortality of in-hospital and within 30, 90, 180, 365 days were significantly higher in patients with DNR (Table1). However, there was no significant difference in the quality of care performance for heart failure patients according to DNR orders (Table2).
Conclusions: In Japan, we do not have official guidelines of DNR orders yet and the interpretation of a DNR order may significantly differs between physicians. Therefore, our hospital program provides physicians with lectures of DNR orders regularly, including the definition of DNR orders, its possible good aspects (e.g. decreasing undesired CPR) as well as its risk (e.g. possibilities of worsening the clinical performance measurement). Although this was a study done in a single center, it suggested that patients with AHF could be treated adequately regardless of presence or absence of DNR orders provided that adequate education about DNR and end-of-life issues is made.
