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Do-not-resuscitate orders as part of advance care planning in patients with COPD

Jo Raskin, Kristina Vermeersch, Stephanie Everaerts, Pascal Van Bleyenbergh, Wim Janssens
ERJ Open Research 2018 4: 00116-2017; DOI: 10.1183/23120541.00116-2017
Jo Raskin
1University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
3These authors contributed equally
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Kristina Vermeersch
1University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
2KU Leuven, Laboratory of Respiratory Diseases, Dept of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
3These authors contributed equally
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Stephanie Everaerts
1University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
2KU Leuven, Laboratory of Respiratory Diseases, Dept of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
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Pascal Van Bleyenbergh
1University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
2KU Leuven, Laboratory of Respiratory Diseases, Dept of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
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Wim Janssens
1University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
2KU Leuven, Laboratory of Respiratory Diseases, Dept of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
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  • For correspondence: wim.janssens@uzleuven.be
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  • FIGURE 1
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    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
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    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

  • Figures
  • TABLE 1

    Specification of first do-not-resuscitate (DNR) order

    DetailsPatients
    DNR 0: do not restrict therapyExplicit statement not to withhold any life-sustaining interventions22 (11)
    DNR 1: do not resuscitateFurther specified as:
     DNR 1aNo CPR47 (24)
     DNR 1bNo CPR + no intubation + NIV to be considered77 (40)
    DNR 2: do not extend therapyNo CPR + no intubation + no NIV46 (24)
    DNR 3: discontinue therapyNo 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 orderPatients with a DNR orderp-value
      Having a DNR order at baselineReceiving a DNR order during follow-up
      Patients n34517177
      Demographic
       Age years72.6±8.879.3±6.076.6±8.3<0.0001
       Female91 (26)5 (29)40 (23)0.565
       BMI kg·m−225.0 (22.4–28.4)24.5 (18.8–26.3)23.4 (20.6–27.4)0.010
       Obese69 (20)3 (18)26 (15)0.309
      Disease severity
       FEV1 L1.4 (1.1–1.8)0.9 (0.6–1.1)1.2 (0.9–1.5)<0.0001
       FEV1 % pred55.0 (41.0–67.0)32.0 (21.0–46.0)42.0 (33.5–54.0)<0.0001
       DLCO L4.4 (3.3–5.6)2.8 (2.3–3.2)3.6 (2.7–4.5)<0.0001
       DLCO % pred53.0 (40.0–67.0)37.0 (28.0–39.5)45.0 (33.0–55.0)<0.0001
       MRCQ score 1–53 (2–3)4 (3–4)3 (2–4)<0.0001
       Chronic oxygen dependency21 (6)8 (47)47 (27)<0.0001
       Previous mechanical ventilation11 (3)2 (12)20 (11)0.001
      DNR order
       0/1a/1b/2/33/6/8/0/0 (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
       Location0.707
          Hospital ward13 (76)122 (69)
          Consultation0 (0)24 (14)
          ER2 (12)15 (8)
          ICU2 (12)15 (8)
          RT0 (0)1 (1)
      Outcome
       Mortality94 (27)14 (82)135 (76)<0.0001
       Follow-up time days1935.0 (1290.0–2448.0)528.0 (136.5–901.0)1322.0 (721.0–2018.5)<0.0001
       Location0.002
          Hospital ward9 (10)10 (72)55 (41)
          ER2 (2)0 (0)6 (5)
          ICU7 (7)2 (14)11 (8)
          Palliative care unit1 (1)0 (0)14 (10)
          Other75 (80)2 (14)49 (36)
       Cause of death<0.0001
          Respiratory4 (4)10 (72)56 (42)
          Cardiac5 (6)1 (7)6 (4)
          Cancer3 (3)0 (0)20 (15)
          Stroke1 (1)0 (0)3 (2)
          Other4 (4)0 (0)12 (9)
          Unknown77 (82)3 (21)38 (28)
       Time between first DNR and death days690.5 (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 status126
        Patient preference37
        Noncurable malignancy25
        Cardiac disease23
        Poor functional status14
        Advanced age11
        Cognitive decline10
        Persistent smoking6
        Request for euthanasia6
        Noncompliance with treatment5
        Obesity5
        Cachexia2
        Declined for lung transplantation2
        Traumatic previous intubation1
        Other medical condition21
        Unknown28

        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 years1.063 (1.037–1.090)<0.001
          Male versus female1.043 (0.638–1.705)0.866
          BMI kg·m−20.982 (0.938–1.027)0.417
          FEV1 % pred0.979 (0.966–0.992)0.002
          DLCO % pred0.988 (0.972–1.003)0.127
          MRCQ score 3–5 versus 1–21.389 (0.883–2.185)0.155
          Chronic oxygen dependency? Yes versus no3.641 (1.995–6.646)<0.001
          Previous mechanical ventilation? Yes versus no3.398 (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 DNRRef.
            DNR 04.984 (2.121–11.71)<0.0001
            DNR 1a4.217 (2.597–6.845)<0.0001
            DNR 1b8.699 (5.860–42.91)<0.0001
            DNR 2/310.36 (6.808–15.79)<0.0001
            Age years1.030 (1.013–1.047)0.001
            FEV1 % pred0.986 (0.978–0.995)0.002
            MRCQ score 3–5 versus 1–21.494 (1.095–2.038)0.011
            Chronic oxygen dependency? Yes versus no1.024 (0.714–1.467)0.899
            Previous mechanical ventilation? Yes versus no1.101 (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 orderPatients with a DNR orderp-value
              Patients n345177
              Survival time days1935.0 (1290.0–2448.0)182.0 (34.0–510.5)<0.0001
              Mortality per time point<0.0001
               Prior to0 (0)2 (1.1)
               Within 48 h after0 (0)7 (3.9)
               Between 3 and 10 days after1 (0.3)15 (8.5)
               Between 11 and 30 days (1 month) after1 (0.3)18 (10.2)
               Between 31 and 90 days (3 months) after5 (1.5)23 (12.9)
               Between 91 and 365 days (1 year) after13 (3.8)37 (20.9)
               Between 366 and 730 days (2 years) after12 (3.5)16 (9.0)
               After 730 days until database completion62 (17.9)17 (9.6)
               Still alive on the date of database completion251 (72.8)42 (23.7)
              Cumulative mortality#<0.0001
               Prior to0 (0)2 (1.1)
               Within 48 h after0 (0)9 (5.1)
               Within 10 days after1 (0.3)24 (13.6)
               Within 30 days (1 month) after2 (0.6)42 (23.7)
               Within 90 days (3 months) after7 (2.0)65 (36.7)
               Within 365 days (1 year) after20 (5.8)102 (57.6)
               Within 730 days (2 years) after32 (9.3)118 (66.7)
               After 730 days until database completion94 (27.2)135 (76.3)
               Still alive on the date of database completion251 (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.

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              Do-not-resuscitate orders as part of advance care planning in patients with COPD
              Jo Raskin, Kristina Vermeersch, Stephanie Everaerts, Pascal Van Bleyenbergh, Wim Janssens
              ERJ Open Research Jan 2018, 4 (1) 00116-2017; DOI: 10.1183/23120541.00116-2017

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              Do-not-resuscitate orders as part of advance care planning in patients with COPD
              Jo Raskin, Kristina Vermeersch, Stephanie Everaerts, Pascal Van Bleyenbergh, Wim Janssens
              ERJ Open Research Jan 2018, 4 (1) 00116-2017; DOI: 10.1183/23120541.00116-2017
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