Deciding whether or not to sign a do-not-resuscitate (DNR) order is a huge decision for a patient and her family. Signing a DNR would signal to health care providers that a patient does not want CPR if her breathing stops or her heart stops beating. Generally DNRs come into play near the end of a patient's life, or if she has an illness that will not improve.

Understandably, many DNRs are ordered for patients with a poor prognosis. One example of this is in-hospital cardiac arrest, which affects about 200,000 patients in the U.S. every year. The rates of favorable neurological survival (survival without severe cognitive disability) are less than 20 percent, so this prognosis often prompts discussions about DNR between doctors and patients. A new study looked to examine the decision to make a DNR order after successful resuscitation from in-hospital cardiac arrest, to see if a patient’s likelihood of favorable neurological survival aligned with the likelihood of getting a DNR.

Dr. Timothy J Fendler, of St. Luke’s Mid America Heart Institute, Kansas City, and colleagues looked at 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest from the Get With The Guidelines-Resuscitation registry. Each patient’s likelihood of favorable neurological survival had been calculated using a diagnostic tool. Researchers calculated the proportion of patients with DNR orders within each prognosis score group and the associatioin between actual DNR orders and favorable neurological survival.

In total, 23 percent of the patients involved had DNR orders within 12 hours of ROSC. Among patients with the best prognosis, 7 percent had DNR orders. This was in spite of the fact that their predicted rate of favorable neurological survival was 65 percent. Among patients with the worst prognosis, only 36 percent had DNR orders, even though their predicted rate for favorable neurological survival was only 4 percent. The actual rate of favorable neurological survival was 31 percent for patients without DNR orders — higher than it was for those with DNR orders, which was 2 percent.

“In the national registry of in-hospital cardiac arrest, we found that DNR orders after successful resuscitation were generally aligned with patients’ likelihood for favorable neurological survival, with increasing rates of DNR orders as a patient’s likelihood to survive without neurological disability decreased,” the authors wrote in the study.

Still though, they note that almost two-thirds of the patients with the worst prognosis did not have DNRs. Also, patients who had DNRs in spite of a good prognosis had a significantly lower survival rate than patients without DNR orders who had a similar prognosis.

“Among patients with a low likelihood of favorable neurological survival after in-hospital cardiac arrest, our findings highlight the potential to improve DNR decision-making,” the authors conclude.

Source: Fendler T, et al. DNR Orders Often Do Not Align With Poor Prognosis. JAMA. 2015.