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Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?

ABSTRACT: Background Women have higher utilization of "do not attempt resuscitation" (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in-hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest from the Get With The Guidelines-Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10-1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30-1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26-1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99-1.02]; P=0.74) was appreciated. Conclusions In patients successfully resuscitated from in-hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.

SUBMITTER: Perman SM

PROVIDER: S-EPMC7070220 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?

Perman Sarah M SM Beaty Brenda L BL Daugherty Stacie L SL Havranek Edward P EP Haukoos Jason S JS Juarez-Colunga Elizabeth E Bradley Steven M SM Fendler Timothy J TJ Chan Paul S PS

Journal of the American Heart Association 20200217 4

Background Women have higher utilization of "do not attempt resuscitation" (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in-hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest from the Get With The Gui ...[more]

PMID: 32063126

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Project description:Statistical models predicting outcome after intraparenchymal hemorrhage include patients irrespective of do-not-attempt-resuscitation orders. We built a model to explore how the inclusion of patients with do-not-attempt-resuscitation orders affects intraparenchymal hemorrhage prognostic models.Retrospective, observational cohort study from May 2001 until September 2003.University-affiliated tertiary referral hospital in Seattle, WA.Four hundred twenty-four consecutive patients with spontaneous intraparenchymal hemorrhage.We retrospectively abstracted information from medical records of intraparenchymal hemorrhage patients admitted to a single hospital. Using multivariate logistic regression of presenting clinical characteristics, but not do-not-attempt-resuscitation status, we generated a prognostic score for favorable outcome (defined as moderate disability or better at discharge). We compared observed probability of favorable outcome with that predicted, stratified by do-not-attempt-resuscitation status. We then generated a modified prognostic score using only non-do-not-attempt-resuscitation patients. Records of 424 patients were reviewed: 44% had favorable outcome, 43% had a do-not-attempt-resuscitation order, and 38% died in hospital. The observed and predicted probability of favorable outcome agreed well with all patients taken together. The observed probability of favorable outcome was significantly higher than predicted in non-do-not-attempt-resuscitation patients and significantly lower in do-not-attempt-resuscitation patients. Results were similar when applying a previously published and validated prognostic score. Our modified prognostic score was no longer pessimistic in non-do-not-attempt-resuscitation patients but remained overly optimistic in do-not-attempt-resuscitation patients.Although our prognostic model was well-calibrated when assessing all intraparenchymal hemorrhage patients, predictions were significantly pessimistic in patients without and optimistic in those with do-not-attempt-resuscitation orders. Such pessimism may drive decisions not to attempt resuscitation in patients in whom a favorable outcome may have been possible, thereby creating a self-fulfilling prophecy. To be most useful in clinical decision making, intraparenchymal hemorrhage prognostic models should be calibrated to large intraparenchymal hemorrhage cohorts in whom do-not-attempt-resuscitation orders were not used.

Project description:BackgroundStudies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival.MethodsPatients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants.ResultsAmong 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P<0.001 for all). A significantly higher proportion of women received DNR orders (35.7% versus 32.1%, P=0.009) and had WLST (32.8% versus 29.8%, P=0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P<0.001; adjusted odds ratio, 0.78 [95% CI, 0.66-0.93]; P=0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P=0.005; adjusted odds ratio, 0.74 [95% CI, 0.60-0.91]) or did not have WLST (32.3% versus 50.7%, P=0.002; adjusted odds ratio, 0.73 [95% CI, 0.60-0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P=0.90) or had WLST (2.8% versus 2.4%, P=0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort.ConclusionsAmong patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.

Dataset Information

Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?

Publications

Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?

Similar Datasets

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