Death and do-not-resuscitate order in the emergency department:A single-center three-year retrospective study in the Chinese mainland

BACKGROUND:Consenting to do-not-resuscitate(DNR)orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments(EDs).The DNR decision in EDs has not been extensively studied,especially in the Chinese mainland.METHODS:This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019.The patients with out-of-hospital cardiac arrest were excluded.RESULTS:There were 214 patients’deaths in the ED in the three years.Among them,132 patients were included in this study,whereas 82 with out-of-hospital cardiac arrest were excluded.There were 99(75.0%)patients’deaths after a DNR order medical decision,64(64.6%)patients signed the orders within 24 hours of the ED admission,68(68.7%)patients died within 24 hours after signing it,and 97(98.0%)patients had DNR signed by the family surrogates.Multivariate analysis showed that four independent factors infl uenced the family surrogates’decisions to sign the DNR orders:lack of referral(odds ratio[OR]0.157,95%confi dence interval[CI]0.047–0.529,P=0.003),ED length of stay(ED LOS)≥72 hours(OR 5.889,95%CI 1.290–26.885,P=0.022),acute myocardial infarction(AMI)(OR 0.017,95%CI 0.001–0.279,P=0.004),and tracheal intubation(OR 0.028,95%CI 0.007–0.120,P<0.001).CONCLUSIONS:In the Chinese mainland,the proportion of patients consenting for DNR order is lower than that of developed countries.The decision to sign DNR orders is mainly affected by referral,ED LOS,AMI,and trachea intubation.

Diagnostic accuracy of ePOS score in predicting DNR labeling after ICU admission:A prospective observational study(ePOS-DNR)

Background Resuscitation can sometimes be futile and making a do-not-resuscitate(DNR)decision is in the best interest of the patient.The electronic poor outcome screening(ePOS)score was developed to predict 6-month poor outcomes of critically ill patients.We explored the diagnostic accuracy of the ePOS score in predicting DNR decisions in the intensive care unit(ICU).Methods This study was conducted at the ICU of a tertiary referral hospital in Saudi Arabia between March and May 2023.Prospectively,we calculated ePOS scores for all eligible consecutive admissions after 48 h in the ICU and recorded the DNR orders.The ability of the score to predict DNR was explored using logistic regression.Youden's ideal cut-off value was calculated using the DeLong method,and different diagnostic accuracy measures were generated with corresponding 95%confidence intervals(CIs).Results We enrolled 857 patients,125 received a DNR order and 732 did not.The average ePOS score of DNR and non-DNR patients was 28.2±10.7 and 15.2±9.7,respectively.ePOS score,as a predictor of DNR order,had an area under receiver operator characteristic(AUROC)curve of 81.8%(95%CI:79.0 to 84.3,P<0.001).Youden's ideal cut-off value>17 was associated with a sensitivity of 87.2(95%CI:80.0 to 92.5,P<0.001),specificity of 63.9(95%CI:60.3 to 67.4,P<0.001),positive predictive value of 29.2(95%CI:24.6 to 33.8,P<0.001),negative predictive value of 96.7(95%CI:95.1 to 98.3,P<0.001),and diagnostic odds ratio 12.1(95%CI:7.0 to 20.8,P<0.001).Conclusions In this study,the ePOS score performed well as a diagnostic test for patients who will be labeled as DNR during their ICU stay.A cut-off score>17 may help guide clinical decisions to withhold or commence resuscitative measures.