Figures
- FIGURE 1
Influence of do-not-resuscitate (DNR) order specification on overall survival in chronic obstructive pulmonary disease (COPD) patients (log rank test p<0.001). Pairwise log rank comparisons revealed significantly different survival distributions at a Bonferroni corrected p<0.01 level, with exception for DNR 0 versus DNR 1a (p=0.470) and DNR 1b versus DNR 2/3 (p=0.361). Due to small sample size of DNR 3 (n=2), DNR 2 and 3 were combined.
- FIGURE 2
a) Mortality per time point (p<0.0001); b) cumulative mortality (p<0.0001) on a nonlinear time scale according to do-not-resuscitate (DNR) status in patients with chronic obstructive pulmonary disease. The median is indicated by the dotted line.
Tables
- TABLE 1
Specification of first do-not-resuscitate (DNR) order
Details Patients DNR 0: do not restrict therapy Explicit statement not to withhold any life-sustaining interventions 22 (11) DNR 1: do not resuscitate Further specified as: DNR 1a No CPR 47 (24) DNR 1b No CPR + no intubation + NIV to be considered 77 (40) DNR 2: do not extend therapy No CPR + no intubation + no NIV 46 (24) DNR 3: discontinue therapy No CPR + no intubation + no NIV + withdrawal of current treatment# 2 (1) Data are presented as n (%). n=194. CPR: cardiopulmonary resuscitation; NIV: noninvasive ventilation. #: treatment of disabling symptoms to be prioritised; however, no life-prolonging interventions are to be continued.
- TABLE 2
Patient characteristics
Patients without a DNR order Patients with a DNR order p-value Having a DNR order at baseline Receiving a DNR order during follow-up Patients n 345 17 177 Demographic Age years 72.6±8.8 79.3±6.0 76.6±8.3 <0.0001 Female 91 (26) 5 (29) 40 (23) 0.565 BMI kg·m−2 25.0 (22.4–28.4) 24.5 (18.8–26.3) 23.4 (20.6–27.4) 0.010 Obese 69 (20) 3 (18) 26 (15) 0.309 Disease severity FEV1 L 1.4 (1.1–1.8) 0.9 (0.6–1.1) 1.2 (0.9–1.5) <0.0001 FEV1 % pred 55.0 (41.0–67.0) 32.0 (21.0–46.0) 42.0 (33.5–54.0) <0.0001 DLCO L 4.4 (3.3–5.6) 2.8 (2.3–3.2) 3.6 (2.7–4.5) <0.0001 DLCO % pred 53.0 (40.0–67.0) 37.0 (28.0–39.5) 45.0 (33.0–55.0) <0.0001 MRCQ score 1–5 3 (2–3) 4 (3–4) 3 (2–4) <0.0001 Chronic oxygen dependency 21 (6) 8 (47) 47 (27) <0.0001 Previous mechanical ventilation 11 (3) 2 (12) 20 (11) 0.001 DNR order 0/1a/1b/2/3 3/6/8/0/0 (18/35/47/0/0) 19/41/69/46/2 (11/23/39/26/1) <0.0001 Time to first DNR order days −230.0 (−409.5–−53.5) 945.0 (386.5–1601.0) <0.0001 Location 0.707 Hospital ward 13 (76) 122 (69) Consultation 0 (0) 24 (14) ER 2 (12) 15 (8) ICU 2 (12) 15 (8) RT 0 (0) 1 (1) Outcome Mortality 94 (27) 14 (82) 135 (76) <0.0001 Follow-up time days 1935.0 (1290.0–2448.0) 528.0 (136.5–901.0) 1322.0 (721.0–2018.5) <0.0001 Location 0.002 Hospital ward 9 (10) 10 (72) 55 (41) ER 2 (2) 0 (0) 6 (5) ICU 7 (7) 2 (14) 11 (8) Palliative care unit 1 (1) 0 (0) 14 (10) Other 75 (80) 2 (14) 49 (36) Cause of death <0.0001 Respiratory 4 (4) 10 (72) 56 (42) Cardiac 5 (6) 1 (7) 6 (4) Cancer 3 (3) 0 (0) 20 (15) Stroke 1 (1) 0 (0) 3 (2) Other 4 (4) 0 (0) 12 (9) Unknown 77 (82) 3 (21) 38 (28) Time between first DNR and death days 690.5 (255.25–872.5) 118.0 (23.0–364.0) <0.0001 Data are presented as n (%), mean±sd or median (interquartile range), unless otherwise stated. DNR: do-not-resuscitate; BMI: body mass index; FEV1: forced expiratory volume in 1 s; DLCO: diffusing capacity of the lung for carbon monoxide; MRCQ: Medical Research Council Questionnaire; ER: emergency room; ICU: intensive care unit; RT: radiotherapy.
- TABLE 3
Reason for implementing a first do-not-resuscitate (DNR) order#
Patients Poor respiratory status 126 Patient preference 37 Noncurable malignancy 25 Cardiac disease 23 Poor functional status 14 Advanced age 11 Cognitive decline 10 Persistent smoking 6 Request for euthanasia 6 Noncompliance with treatment 5 Obesity 5 Cachexia 2 Declined for lung transplantation 2 Traumatic previous intubation 1 Other medical condition 21 Unknown 28 Data are presented as n. N=194. #: the reason for implementing a first DNR order was recorded in a text box which permitted the documentation of more than one reason, and its completion was not mandatory.
- TABLE 4
Multivariate logistic regression model: determinants associated with do-not-resuscitate (DNR) order implementation
Odds ratio (95% CI) p-value Age years 1.063 (1.037–1.090) <0.001 Male versus female 1.043 (0.638–1.705) 0.866 BMI kg·m−2 0.982 (0.938–1.027) 0.417 FEV1 % pred 0.979 (0.966–0.992) 0.002 DLCO % pred 0.988 (0.972–1.003) 0.127 MRCQ score 3–5 versus 1–2 1.389 (0.883–2.185) 0.155 Chronic oxygen dependency? Yes versus no 3.641 (1.995–6.646) <0.001 Previous mechanical ventilation? Yes versus no 3.398 (1.469–7.860) 0.004 Bold type represents statistical significance. BMI: body mass index; FEV1: forced expiratory volume in 1 s; DLCO: diffusing capacity of the lung for carbon monoxide; MRCQ: Medical Research Council Questionnaire.
- TABLE 5
Cox regression analysis of do-not-resuscitate (DNR) order implementation#
Hazard ratio (95% CI) p-value No DNR Ref. DNR 0 4.984 (2.121–11.71) <0.0001 DNR 1a 4.217 (2.597–6.845) <0.0001 DNR 1b 8.699 (5.860–42.91) <0.0001 DNR 2/3 10.36 (6.808–15.79) <0.0001 Age years 1.030 (1.013–1.047) 0.001 FEV1 % pred 0.986 (0.978–0.995) 0.002 MRCQ score 3–5 versus 1–2 1.494 (1.095–2.038) 0.011 Chronic oxygen dependency? Yes versus no 1.024 (0.714–1.467) 0.899 Previous mechanical ventilation? Yes versus no 1.101 (0.676–1.792) 0.699 Bold type represents statistical significance. #: adjusted for age, forced expiratory volume in 1 s (FEV1), Medical Research Council Questionnaire (MRCQ) score, chronic respiratory dependency and previous need for mechanical ventilation. ref.: reference against which other DNR values are compared.
- TABLE 6
Frequency distribution for mortality
Patients without a DNR order Patients with a DNR order p-value Patients n 345 177 Survival time days 1935.0 (1290.0–2448.0) 182.0 (34.0–510.5) <0.0001 Mortality per time point <0.0001 Prior to 0 (0) 2 (1.1) Within 48 h after 0 (0) 7 (3.9) Between 3 and 10 days after 1 (0.3) 15 (8.5) Between 11 and 30 days (1 month) after 1 (0.3) 18 (10.2) Between 31 and 90 days (3 months) after 5 (1.5) 23 (12.9) Between 91 and 365 days (1 year) after 13 (3.8) 37 (20.9) Between 366 and 730 days (2 years) after 12 (3.5) 16 (9.0) After 730 days until database completion 62 (17.9) 17 (9.6) Still alive on the date of database completion 251 (72.8) 42 (23.7) Cumulative mortality# <0.0001 Prior to 0 (0) 2 (1.1) Within 48 h after 0 (0) 9 (5.1) Within 10 days after 1 (0.3) 24 (13.6) Within 30 days (1 month) after 2 (0.6) 42 (23.7) Within 90 days (3 months) after 7 (2.0) 65 (36.7) Within 365 days (1 year) after 20 (5.8) 102 (57.6) Within 730 days (2 years) after 32 (9.3) 118 (66.7) After 730 days until database completion 94 (27.2) 135 (76.3) Still alive on the date of database completion 251 (72.8) 42 (23.7) Data are presented as median (interquartile range) or n (%), unless otherwise stated. DNR: do-not-resuscitate. #: values relative to date of enrolment or implementation of DNR order for patients without and with a DNR order, respectively.
