Effect of a do-not-resuscitate order on the quality of care in acute heart failure patients: a single-center cohort study

Figures & data

Figure 1 Main points of the do-not-resuscitate (DNR) lectures given to participants in Tokyo Bay Urayasu Ichikawa Medical Center.

Table 1 Patient characteristics according to DNR status

Characteristics	Absence of DNR order (N=280)	Presence of DNR order (N=114)	P-value
Age, years	69±14	82±8	<0.001
Age >75 years	124 (44)	88 (77)	<0.001
Sex, male	173 (62)	46 (40)	<0.001
Comorbidities
Hypertension	163 (58)	77 (67)	0.09
COPD	13 (4.6)	3 (2.6)	0.57
Malignancy	19 (6.8)	10 (8.8)	0.53
CKD	48 (17)	24 (21)	0.39
Hemodialysis	23 (8.2)	6 (5.3)	0.40
DM	85 (30)	31 (27)	0.63
Medical history
Stroke	35 (13)	17 (15)	0.52
Myocardial infarction	32 (11)	11 (9.6)	0.72
PCI	18 (6.4)	6 (5.3)	0.82
CABG	10 (3.6)	6 (5.3)	0.41
Valve surgery	7 (2.5)	2 (1.8)	1.0
Pace maker	6 (2.1)	5 (4.4)	0.31
Current smoking	63 (23)	11 (9.7)	<0.001
History of AHF hospitalization	92 (35)	44 (40)	0.29
Dementia	28 (11)	47 (41)	<0.001
ADL-dependent	41 (15)	52 (46)	<0.001
Decision-making capacity: complete	263 (94)	74 (66)	<0.001
Systolic blood pressure, mmHg	152±35	149±39	0.59
Diastolic blood pressure, mmHg	91±23	83±24	0.004
Heart rate, beats/minute	99±28	90±24	0.005
Acute coronary syndrome	42 (15)	10(8.8)	0.10
Acute infection	38 (15)	14 (14)	1.0
Echocardiography: ejection fraction, %	41±16	44±16	0.09
Laboratory data
Hemoglobin, g/dL	12.5±2.4	11.0±2.1	<0.001
Blood urea nitrogen, mg/dL	25±16	31±18	0.003
Creatinine, mg/dL	1.8±2.6	1.7±1.7	0.58
Inhospital mortality	7(2.5)	17(15)	<0.001

Note: Values are presented as mean±SD or n (%).

Abbreviations: DNR, do-not-resuscitate order; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease; DM, diabetes mellitus; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft; AHF, acute heart failure; ADL, activities of daily living.

Table 2 Characteristics of HF patients with reduced ejection fraction according to DNR status

Characteristics	Absence of DNR (N=139)	Presence of DNR (N=44)	P-value
Age, years	65±5	81±9	<0.001
Age >75 years	48 (35)	30 (68)	<0.001
Male	105 (77)	28 (64)	0.12
Comorbidities
Hypertension	69 (50)	26 (60)	0.30
COPD	2 (1.4)	1 (2.3)	0.56
Malignancy	8 (5.8)	5 (11)	0.31
CKD	19 (14)	10 (23)	0.16
HD	11 (7.9)	3 (6.8)	1.0
DM	41 (30)	15 (34)	0.58
Medical history
Stroke	16 (12)	11 (25)	0.048
Myocardial infarction	18 (13)	8 (18)	0.46
PCI	8 (5.8)	2 (4.5)	1.0
CABG	4 (2.9)	4 (9.1)	0.096
Valve surgery	1 (0.7)	0	1.0
Pacemaker	1 (0.7)	1 (2.3)	0.42
Current smoker	43 (31)	8 (18)	0.26
AHF hospitalization	44 (34)	21 (48)	0.11
Dementia	13 (9.4)	20 (46)	<0.001
ADL-dependent	12 (8.6)	19 (43)	<0.001
Decision-making capacity: complete	132 (95)	27 (62)	<0.001
Systolic blood pressure, mmHg	148±34	144±37	0.62
Diastolic blood pressure, mmHg	95±23	87±29	0.08
Heart rate, beats/minute	108±29	94±26	0.004
Acute coronary syndrome	26 (19)	8 (18)	1.0
Acute infection	20 (15)	6 (15)	1.0
Echocardiography: ejection fraction, %	27±8	27±8	0.69
Laboratory data
Hemoglobin, g/dL	13.2±2.7	11.2±2.1	<0.001
Blood urea nitrogen, mg/dL	26±16	39±24	0.002
Creatinine, mg/dL	1.8±2.9	1.8±1.6	0.84
Inhospital mortality	6 (4.3)	7(16)	0.016

Note: Values are presented as mean±SD or n (%).

Abbreviations: HF, heart failure; DNR, do-not-resuscitate order; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease; HD, heart disease; DM, diabetes mellitus; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft; AHF, acute heart failure; ADL, activities of daily living.

Table 3 DNR order and quality measures among acute heart failure inpatients

Quality measure	Absence of DNR order	Presence of DNR order	P-value	RR (95% CI)
Echocardiography	280/280 (100%)	113/114 (99%)	0.29	0.99 (0.97–1.01)
Anticoagulation for atrial fibrillation	71/73 (97%)	18/18 (100%)	1.0	1.03 (0.99–1.07)
Beta-blocker for LVSD	115/122 (94%)	33/35 (94%)	1.0	1.0 (0.91–1.10)
ACE inhibitor or ARB for LVSD	106/118 (90%)	28/29 (97%)	0.47	1.07 (0.98–1.18)

Abbreviations: DNR, do-not-resuscitate order; RR, relative risk; LVSD, left ventricular systolic dysfunction; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor antagonist; CI, confidence interval.