Background: COVID-19  has claimed over 260,000 American lives (1), disproportionately affecting older adults (2). High mortality rates in older adults, along with the potential need for resource allocation, placed an even higher importance on the timely discussion and documentation of advance directives (3). The aim of our study was to determine the prevalence of early do-not-resuscitate orders (within 24 hours of admission) during the peak of COVID-19 pandemic as well as associations between early DNR, patient characteristics and hospital outcomes.

Methods: A retrospective cohort study was conducted of all older adults, 65+, hospitalized with COVID-19 across a large health system in the greater NY metropolitan area, between March-April 2020. An early DNR was defined as having an order within 24 hours. The non-early DNR group consisted of those without a DNR order or those with a DNR order placed after 24 hours of admission. In addition, patient demographics (age, gender, race), baseline characteristics (arrived from location and comorbidities), severity of illness on presentation (modified early warning score, MEWS, and oxygen requirement) were collected. Our primary outcome was in-hospital mortality. Secondary outcomes included surrogates for suffering in this population, namely intubation and delirium (physical restraints and antipsychotics)

Results: Of 4961 older adults admitted with COVID-19 during the study period, only 283 (5.7%) had an early DNR order, 1557 (31.4%) had a late DNR, and 3121 (62.9%) had no DNR order during admission. Overall, 1747 (35.2%) expired during admission; 182 (64.3%) in the early DNR group and 1565 (33.5%) in the non-DNR group. The early DNR group, as compared to the non-early DNR group, was older (average age 85.0 vs. 77.0, p<0.001), female (51.2% vs. 43.6%, p=0.0118), and White (7.06%) as opposed to Black, Asian, or other (3.10%, 6.03%, 5.11%, p=.0002). Additionally, those with an early DNR order were more likely to come from a non-home facility (13.4% vs. 3.65%, p<0.001), have dementia (13.29% vs. 4.57%, p<0.001), and a higher Charlson Comorbidity Index (3.88 vs. 3.36, p<0.001). With regard to hospital outcomes, when controlling for patient demographics, baseline characteristics, and severity of illness on presentation, an early DNR order was associated with higher hospital mortality (OR 2.94, 95% CI 2.1-4.1), lower odds of intubation (OR 0.37, 95% CI 0.21-0.67, p=.001) and lower risk of delirium necessitating physical restraints or antipsychotics (OR 0.55,0.40-0.77, p=.0004).

Conclusions: Prevalence of orders for early DNR in older adults hospitalized with COVID-19 during peak pandemic was low. Our study shows that although patients with early DNR were at increased risk of hospital mortality, they were also less likely to experience distressing events such as intubation and delirium. Early discussions and documentation of advance directives are important to patient care but are even more essential during a pandemic. Future studies are necessary to understand the role of DNR in receiving preference-congruent care.