NDLI: Variation in the rates of do not resuscitate orders after major trauma and the impact of intensive care unit environment.

Content Provider	World Health Organization (WHO)-Global Index Medicus
Author	Nathens, Avery B. Rivara, Frederick P. Wang, Jin Mackenzie, Ellen J. Jurkovich, Gregory J.
Spatial Coverage	United States
Description	Country affiliation: Canada Author Affiliation: Nathens AB ( Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada. nathensa@smh.toronto.on.ca)
Abstract	BACKGROUND: There is an increased emphasis on benchmarking of trauma mortality outcomes as a measure of quality. Differences in approaches to end-of-life care or perceptions of salvageability might account for some of the variability in outcomes across centers. We postulated that these differences in perceptions or practice might lead to significant variation in the use of do not resuscitate (DNR) orders and sought to identify institutional characteristics associated with their use. METHODS: Patients surviving >24 hours and admitted to an intensive care unit (ICU) in one of 68 centers across the United States were identified from a large prospective cohort study of severely injured patients. Independent predictors of a DNR order at both the patient and institutional level were identified using multivariate hierarchical modeling stratified by age <55 or >/=55. RESULTS: Of 6,765 patients, 7% had a DNR order, of whom 88% died. The proportion of patients in each center with a DNR order ranged from 0% to 57%. Independent patient-level predictors associated with a DNR order were increasing age, preinjury comorbidity burden, severe injury, and organ failure. Institutional predictors of DNR orders differed by age. Care in an open ICU was associated with a DNR order (odds ratio, 1.7; 95% confidence interval, 1.0-3.0) in the elderly, whereas care in a combined medical-surgical ICU (vs. surgical or trauma ICU) was associated with greater likelihood (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) of a DNR order in the young. CONCLUSIONS: DNR orders are relatively common in seriously injured trauma patients, and there is significant variability in their use across centers. Given the institutional characteristics independently associated with DNR status, it is likely that both differences in the ethos of end-of-life care and perceptions of salvageability affect decision making.
File Format	HTM / HTML
ISSN	00225282
Issue Number	1
Volume Number	64
e-ISSN	15298809
Journal	The Journal of Trauma: Injury, Infection, and Critical Care
Language	English
Publisher	Lippincott Williams & Wilkins
Publisher Date	2008-01-01
Publisher Place	United States
Access Restriction	Subscribed
Subject Keyword	Multivariate Analysis Hospital Bed Capacity Prospective Studies Age Factors United States Wounds And Injuries Humans Middle Aged Trauma Centers Male Epidemiology Journal Article Injury Severity Score Female Odds Ratio Intensive Care Units Comorbidity Mortality Logistic Models Trauma Severity Indices Discipline Traumatology Organizational Culture Research Support, U.s. Gov't, P.h.s. Organization & Administration Resuscitation Orders Aged
Content Type	Text
Resource Type	Article
Subject	Surgery Critical Care and Intensive Care Medicine

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