Early and late do-not-resuscitate (DNR) decisions in patients with terminal COPD: a retrospective study in the last year of life

Figures & data

Table 1 Demographic characteristics of patients with COPD who died in a medical center over a period of 5 years (2011–2015) (N=271)

Characteristics	Data
Age (Median, IQR)	83 (77–88)
Male	249 (91.9%)
Pulmonary function test within 1 year prior to death (Median, IQR) (n=96)
FEV1/FVC%	48.5 (39–62)
FEV1%	60.5 (40–81.8)
Medical utilization within 1 year prior to death (Median, IQR)
Number of ER visits	2 (1–3)
Number of hospitalizations	1 (1–3)
Experienced CPR	18 (6.6%)
Medical utilization in the last admission
Admitted from ER	256 (94.5%)
Died on the service of a pulmonologist	162 (59.8%)
Died in the ICU	88 (32.5%)
Experienced mechanical ventilation	225 (83.0%)
Had only Invasive MV	119 (43.9%)
Had only NIPPV	106 (39.1%)
Ever had both MV and NIPPV	64 (23.6%)
Extubated with NIPPV support	136 (50.2%)
Clinical indicators for palliative care (Median, IQR)	4 (3–5)
Patient wishes recorded (DNR)	234 (86.3%)
DNR in the last admission prior to death	164 (70.1%)
DNR within 30 days prior to death	175 (74.8%)
Time period from DNR request to death (Median, IQR)	8.5 (3–32)
Terminal status certified by a physician	30 (11.1%)
Terminal status certificated in the last admission (n=30)	24 (80.0%)

Abbreviations: DNR, do-not-resuscitate; ER, emergency room; FEV₁, forced expiration volume in the first second of expiration; FVC, forced vital capacity; ICU, intensive care unit; IQR, interquartile range; MV, mechanical ventilator; NIPPV, non-invasive positive pressure ventilator.

Figure 1 Study flow chart.

Notes: “Early DNR” was defined as “COPD patients or their surrogates who had DNR directive prior to their last admission.” “Late DNR” was defined as “COPD patients or their surrogates who had DNR directive during their last admission.”
Abbreviations: DNR, do-not-resuscitate; EHR, Electronic health records.

Table 2 The official indicators of “terminal status in COPD” in Taiwan

Criteria	Fit cases (n, %)
1) Respiratory insufficiency (even with oxygen support, PaO2≤55 mmHg, PaCO2 ≥50 mmHg or O2 saturation ≤88%)	255 (94.1%)
2) FEV1≤30% of predicted	44 (16.2%)
3) FEV1 declined ≥40 mL/year	72 (26.6%)
4) Weight loss ≥10% in 6 months	106 (39.1%)
5) Resting heart rate ≥100/min	212 (78.2%)
6) Right-sided heart failure	116 (42.8%)
7) Multiple comorbidities: (eg, cachexia, recurrent infection, depression, or multiple comorbidities)	243 (89.7%)

Note: “Terminal status in COPD”: for COPD patients who suffered from breathlessness even when resting, and the condition continued to deteriorate (such as: repeated ER visits or hospitalizations due to pneumonia or respiratory failure), combined with any of the above conditions.

Abbreviation: FEV₁, forced expiration volume in the first second of expiration.

Table 3 Comparison of care pattern and terminal criteria between “Early DNR” and “Late DNR”

Characteristics	Early DNR (N=70)	Late DNR (N=164)	P-value
Age (Median, IQR)	87 (83–90)	82 (75–85.75)	<0.001**
Male	62 (88.6%)	154 (93.9%)	0.257
Lung function test within 1 year prior to death (Median, IQR) (n=24 vs 56a)
FEV1%	51.5 (38.3–77.3)	59 (38.5–81.8)	0.785
Medical utilization within 1 year prior to death (Median, IQR)
Number of ER visits	3 (2–6)	1 (1–3)	<0.001**
Number of hospitalizations	2 (1–4)	1 (1–2)	<0.001**
Experienced CPR	2 (2.9%)	4 (2.4%)	1.000
Terminal status recorded by physicians	13 (18.6%)	17 (10.4%)	0.132
Numbers of clinical indicators met for terminal status	4 (3–5)	3 (3–4.75)	0.001**
Items that meet the official indicator of terminal status:
1) Respiratory insufficiency (even with oxygen support, PaO2≤55 mmHg, PaCO2≥50 mmHg or O2 saturation ≤88%)	66 (94.3%)	156 (95.1%)	0.755
2) FEV1≤30% of predicted	16 (22.9%)	24 (14.6%)	0.180
3) FEV1 declined ≥40 mL/year	27 (38.6%)	36 (22.0%)	0.014*
4) Weight loss ≥10% in 6 months	26 (37.1%)	68 (41.5%)	0.637
5) Resting heart beats ≥100/min	61 (87.1%)	119 (72.6%)	0.024*
6) Right side heart failure	43 (61.4%)	64 (39.0%)	0.003**
7) Multiple comorbidities: (eg, cachexia, recurrent infection, depression or multiple comorbidities)	65 (92.9%)	147 (89.6%)	0.597
Time periods from making DNR directives to death	68.5 (10.5–292.8)	5 (2–14.8)	<0.001**
Medical utilization in the last admission
Admitted from ERa	68 (97.1%)	153 (93.3%)	0.354
Died on the service of a pulmonologist	44 (62.9%)	97 (59.1%)	0.700
Died in the ICU	5 (7.1%)	65 (39.6%)	<0.001**
Experienced mechanical ventilator	48 (68.6%)	145 (88.4%)	0.001**
Only using invasive MV	8 (11.4%)	85 (51.8%)	<0.001**
Only using NIPPV	40 (57.1%)	60 (36.6%)	0.006**
Extubated with NIPPV support	39 (55.7%)	89 (54.3%)	0.952
Length of stay in the last admission	11.5 (4.0–21.0)	19.0 (10.0–34.8)	<0.001**

Notes: Mann–Whitney U test. Chi-squared test.

a Fisher’s exact test;

* P<0.05,

** P<0.01.

a Not everyone has lung function data in their last year.

Abbreviations: CPR, cardio-pulmonary resuscitation; DNR, do not resuscitate; ER, emergency room; FEV₁, forced expiration volume in the first second of expiration; ICU, intensive care unit; IQR, interquartile range; MV, mechanical ventilator; NIPPV, Non-invasive positive pressure ventilator.

Figure 2 Period of time from DNR directive to death between “Early DNR” and “Late DNR” groups in terminal patients with COPD.

Notes: Median: 68.5 days and 5 days, respectively, P<0.001.
Abbreviation: DNR, do not resuscitate.

Table 4 Factors associated with EDNR

Characteristics	Univariate analysis			Multivariate analysis
	OR	95% CI	P-value	OR	95% CI	P-value
Age	1.08	(1.04–1.13)	<0.001**	1.07	(1.02–1.12)	0.005**
Male	0.50	(0.19–1.33)	0.168
Lung function test within 1 year prior to death
FEV1%	1.00	(0.98–1.01)	0.688
Medical utilization within 1 year prior to death
Number of ER visits	1.25	(1.13–1.38)	<0.001**	1.22	(1.10–1.37)	<0.001**
Number of hospitalizations	1.11	(0.98–1.26)	0.093
Number of clinical indicators met for terminal status	1.32	(1.09–1.60)	0.005**	0.68	(0.44–1.06)	0.091
Experienced CPR	1.18	(0.21–6.58)	0.853
Terminal status certificated by physicians	1.97	(0.90–4.32)	0.090
Terminal criteria
1) Respiratory insufficiency (even with oxygen support, PaO2≤55 mmHg, PaCO2≥50 mmHg or O2 saturation ≤88%)	0.85	(0.25–2.91)	0.791
2) FEV1≤30% of predicted	1.73	(0.85–3.50)	0.129
3) FEV1 declined ≥40 mL/year	2.23	(1.22–4.10)	0.009**	3.42	(1.12–10.48)	0.031*
4) Weight loss ≥10% in 6 months	0.83	(0.47–1.48)	0.537
5) Resting heart beats ≥100/min	2.56	(1.18–5.59)	0.018*	3.02	(1.07–8.51)	0.036*
6) Right side heart failure	2.49	(1.40–4.42)	0.002**	2.38	(1.10–5.19)	0.028*
7) Multiple comorbidities: (eg, cachexia, recurrent infection, depression or multiple comorbidities)	1.50	(0.53–4.25)	0.442

Notes: Logistic regression.

* P<0.05,

** P<0.01.

Abbreviations: CPR, cardio-pulmonary resuscitation; EDNR, early do-not-resuscitate; ER, emergency room; FEV₁, forced expiration volume in the first second of expiration.