Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure
Received 18 October 2007; accepted 24 January 2008. published online 14 April 2008.
Background
Heart failure (HF) is one of the leading causes of morbidity and mortality among Americans. Despite increased interest in end-of-life care, the implications of do-not-resuscitate (DNR) orders in acutely ill patients with HF remain unclear. The goals of this observational study were to describe the use of DNR orders and their impact on treatment approaches in residents of a large New England metropolitan area hospitalized with acute heart failure.
Methods
Use of HF performance measures, including assessment of left ventricular function, use of angiotensin receptor blocking agents, anticoagulation, smoking cessation counseling, and use of nonpharmacologic strategies, was examined through review of the medical records of 4,537 metropolitan Worcester (MA) residents admitted to 11 central Massachusetts hospitals with acute HF in 1995 and 2000 according to the presence of DNR orders.
Results
Patients with DNR orders were less likely to have had their left ventricular function assessed (31% vs 43%) as well as receive renin-angiotensin system blockade (49% vs 57%), anticoagulation (65% vs 78%), or nonpharmacologic interventions (87% vs 92%) as compared to patients without DNR orders. Patients with DNR orders were significantly less likely to have received any quality assurance measure for acute HF (adjusted hazard ratio 0.63, 95% confidence interval 0.40-0.99) than patients without DNR orders.
Conclusions
The use of quality assurance measures in acute HF is markedly lower in patients with DNR orders. The implications of DNR orders need to be further clarified in the treatment of patients with acute HF.
aRenal Section, Boston University School of Medicine, Boston, MA
bDivision of Nephrology and Hypertension, Miller School of Medicine at the University of Miami, Miami, FL
cDivision of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA
Reprint requests: Joline L.T. Chen, MD, MS, Renal Section, Boston University School of Medicine, EBRC Suite 504, 650 Albany St, Boston, MA 02118.
This research was made possible by the cooperation of the medical records, administration, and cardiology departments of participating hospitals in the Worcester metropolitan area and through funding support provided by the National Institutes of Health, Bethesda, MD (R37 HL69874).
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