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

doi:10.5847/wjem.j.1920-8642.2020.04.005

Abstract

Abstract:

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 influenced the family surrogates’ decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence 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.

Key words: Emergency service, Do-not-resuscitate, Death patients, Retrospective analysis, Emergency departments

Chuan-qi Ding, Yu-ping Zhang, Yu-wei Wang, Min-fei Yang, Sa Wang, Nian-qi Cui, Jing-fen Jin. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland[J]. World Journal of Emergency Medicine, 2020, 11(4): 231-237.

Figures/Tables 5

Figure 1.

Table 1

Table 2

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Table 4

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Variables	n (%)
Demographic characteristics
Age (years), median (IQR)	77 (55.25, 87.75)
Sex
Male	88 (66.7)
Female	44 (33.3)
Living of place
Countryside	21 (15.9)
City	111 (84.1)
Expense category
Self-supporting	35 (26.5)
Medical insurance	97 (73.5)
Duration from morbidity to signing DNR (hours), median (IQR)	14 (2, 42)
Pre-hospital information
Referral
No	91 (68.9)
Yes	41 (31.1)
30-day readmission
Yes	54 (40.9)
No	78 (59.1)
Ambulance transfer
Yes	108 (81.8)
No	24 (18.2)
Triage
Level I	73 (55.3)
Level II	31 (23.5)
Level III	21 (15.9)
Level IV	2 (1.5)
Level V	5 (3.8)
Clinical department
Internal medicine	61 (46.2)
Neurology department	37 (28.0)
Cardiology department	11 (8.3)
Emergency department	10 (7.6)
Neurosurgery department	8 (6.1)
Surgical department	5 (3.8)

Variables	n (%)
CCI (mean±SD)	4.39±2.61
ED LOS (hours), median (IQR)	25.50 (10.25, 83.50)
Acute medical disorders
ACVD	44 (33.3)
AHDT	10 (7.6)
Shock	10 (7.6)
Multiple trauma	9 (6.8)
AMI	5 (3.8)
Toxicosis	4 (3.0)
AECOPD	2 (1.5)
Chronic underlying diseases
Malignancy	26 (19.7)
Chronic respiratory disease	24 (18.2)
Coronary artery disease	17 (12.9)
Chronic renal disease	11 (8.3)
Chronic liver disease	10 (7.6)
Dementia	4 (3.0)
Organ failures
Respiratory failure	17 (12.9)
Renal insufficiency	15 (11.4)
Heart failure (NYHA class 4)	14 (10.6)
Hepatic insufficiency	8 (6.1)
Main medical disorders
Neurological	49 (37.1)
Cardiovascular	27 (20.5)
Respiratory	27 (20.5)
Cancer	26 (19.7)
Infectious	24 (18.2)
Digestive	16 (12.1)
Traumatic	9 (6.8)
Death trajectory
Frailty	45 (34.1)
Sudden death	42 (31.8)
Organ failure	25 (18.9)
Terminal illness	20 (15.2)

Variables	DNR (n=99)	Without DNR (n=33)	P-value
Age (years), median (IQR)	82 (63, 89)	59 (45, 73)	<0.001
Male	66 (66.7)	22 (66.7)	1.000
City	89 (89.9)	22 (66.7)	0.002
Medical insurance	82 (82.8)	15 (45.5)	<0.001
No referral	76 (76.8)	15 (45.5)	0.001
30-day readmission	40 (40.4)	14 (42.4)	0.838
Ambulance transfer	82 (82.2)	26 (78.8)	0.602
Triage			0.060
Level I	54 (54.5)	19 (57.6)
Level II	27 (27.3)	4 (12.1)
Level III	15 (15.2)	6 (18.2)
Level IV	0 (0)	2 (6.1)
Level V	3 (3.0)	2 (6.1)
CCI (mean±SD)	4.83±2.49	3.06±2.55	0.001
ED LOS (hours), median (IQR)	29 (13, 99)	12 (3, 59)	0.008
Trachea intubation	26 (26.3)	28 (84.8)	<0.001
Invasive mechanical ventilation	25 (25.3)	28 (84.8)	<0.001
Electric cardioversion	0 (0)	2 (6.1)	0.061
Central venous catheter	13 (13.1)	7 (21.2)	0.400
Indwelling gastric tube	19 (19.2)	5 (15.2)	0.602
Indwelling catheter	57 (57.6)	20 (60.6)	0.760
AMI	1 (1.0)	4 (12.1)	0.018
ACVD	32 (32.3)	12 (36.4)	0.670
AHDT	9 (9.1)	1 (3.0)	0.447
AECOPD	2 (2.0)	0 (0)	1.000
Multiple trauma	4 (4.0)	5 (15.2)	0.073
Shock	7 (7.1)	3 (9.1)	1.000
Toxicosis	3 (3.0)	1 (3.0)	1.000
Coronary artery disease	12 (12.1)	5 (15.2)	0.881
Chronic respiratory disease	19 (19.2)	5 (15.2)	0.602
Malignancy	22 (22.2)	4 (12.1)	0.206
Liver disease	9 (9.1)	1 (3.0)	0.447
Renal disease	8 (8.1)	3 (9.1)	1.000
Dementia	4 (4.0)	0 (0)	0.558

Variables	Univariate analysis			Multivariate analysis
Variables	OR	95% CI	P-value	OR	95% CI	P-value
Age	1.045	1.022-1.068	<0.001	-	-	-
Living in city	4.450	1.678-11.801	0.003	-	-	-
Medical insurance	5.788	2.445-13.700	<0.001	-	-	-
No referral	0.252	0.110-0.578	0.001	0.157	0.047-0.529	0.003
CCI >3	5.084	2.195-11.772	<0.001	-	-	-
ED LOS ≥72 hours	3.152	1.018-9.757	0.046	5.889	1.290-26.885	0.022
AMI	0.074	0.008-0.688	0.022	0.017	0.001-0.279	0.004
Traumatic	0.236	0.059-0.938	0.040	-	-	-
Trachea intubation	0.064	0.022-0.182	<0.000	0.028	0.007-0.120	<0.001
Mechanical ventilation	0.060	0.021-0.173	<0.000	-	-	-

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