Author + information
DNR order is a vital determinant contributing to a worse outcome for out-of-hospital cardiac arrest (OHCA). However, our data showed that a small percentage of those OHCA patients with Do-not-resuscitate (DNR) order signed in hospital survived to hospital discharge and even some of them had a favorable neurological recovery. In this study, we were to describe the characteristics of these survivors and to determine those factors which were independently associated with survival to hospital discharge and favorable neurological outcome as well.
A secondary, observational, retrospective analysis was performed on all adult non-traumatic OHCA in DFW EPISTRY and PRIMED studies from January 2006 through April 2011. Of a total of 10994 OHCA cases, 3874(35.2%) of them were treated, stabilized and admitted to hospital; Among all these admitted cases, 2288(59.1%) patients who were put on DNR order made in the hospital for various reasons, were enrolled in this study. We reported the demographics, pre-hospital characteristics, key interventions in ER and those in hospital for all enrolled cases. Multivariable logistic regression models assessed factors associated with survival to hospital discharge as well as favorable neurological outcome at hospital discharge for OHCA patients with DNR order signed in hospital.
Of all the 2288 OHCA patients who were admitted to hospital but had DNR order made in hospital, 132(5.8%) survival to hospital discharge and 28(1.2%) obtained good functional recovery. Being witnessed by ED or bystanders (OR 2.541; 95%CI 1.542-4.243;P=0.000), cardiovascular interventions or procedures (OR2.179; 95%CI1.393-3.409;P=0.001), high dose adrenalin administration (>3mg) (OR0.513;95%CI 0.286-0.922;P=0.026), advanced airway applied in the field (OR0.498;95%CI 0.279-0.889;P=0.018), CPR attempt in ED or in hospital(OR0.520;95%CI0.333-0.811;P=0.004), pre-hospital response time (OR0.923;95%CI 0.857-0.994;P=0.034) were independently associated with survival to hospital discharge. Further analysis showed that cardiovascular interventions or procedures(OR4.830;95%CI 2.058-11.336; P=0.000) and CPR attempt in ED or in hospital (OR0.206;95%CI 0.063-0.676;P=0.009) were independently associated with favorable neurological outcomes.
Some of hospitalized OHCA patients survived to hospital discharge with favorable neurological outcomes even when DNR order was signed in hospital. Such factors as witnessed arrest, cardiovascular interventions or procedures, administrated adrenalin dosage, advanced airway applied in the field, CPR attempted in ED or in hospital, pre-hospital response time, were significant predictors to survival for admitted OHCA cases with DNR order signed in hospital.