This Article Résumé de cet Article Full Text Full Text (PDF) Additional Material Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sinuff, T. Search for Related Content PubMed PubMed Citation Articles by Sinuff, T.

DNR directives are established early in mechanically ventilated intensive care unit patients

[Les directives PDR sont établies tôt chez les patients sous ventilation mécanique à l’unité des soins intensifs]

Tasnim Sinuff, MD^*, Deborah J. Cook, MD^*,, Graeme M. Rocker, DM, Lauren E. Griffith, MSc, Stephen D. Walter, PhD, Malcolm M. Fisher, MD, Peter M. Dodek, MD^¶, Peter Sjokvist, MD, Ellen McDonald, RN, John C. Marshall, MD^**, Peter A. Kraus, MD^*, Mitchell M. Levy, MD, Neil M. Lazar, MD and Gordon H. Guyatt, MD^*, for The Level Of Care Study Investigators & The Canadian Critical Care Trials Group

^* From the Departments of Medicine and
Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada;
the Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada;
the Intensive Therapy Unit, Royal North Shore Hospital, University of Sydney, Sydney, Australia;
^¶ the Program of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver, British Columbia, Canada; the Department of Anesthesia & Intensive Care, Huddinge University, Stockholm, Sweden;
^** the Department of Surgery, University of Toronto, Toronto, Ontario, Canada;
the Department of Medicine, Brown University, Providence, Rhode Island, USA; and
the Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada.

Address correspondence to: Dr. D. J. Cook, Department of Medicine & Epidemiology and Biostatistics, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada. Phone: 905-525-9140, ext. 22900; Fax: 905-524-3841; E-mail: debcook{at}mcmaster.ca

Purpose: Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

Methods: In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

Results: Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [ 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74 yr (HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3–2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4–2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7–33.6)], 10 to 40% [(HR 5.0, 2.3–11.2), 41 to 60% (HR 4.0, 1.8–9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6–9.4) or partial advanced life support (HR 3.2, 2.2–4.6) compared to full measures].

Conclusion: One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.

This article has been cited by other articles:

				D. Cook, G. Rocker, J. Marshall, L. Griffith, E. McDonald, G. Guyatt, and for the Level of Care Study Investigators and the Levels of Care in the Intensive Care Unit: A Research Program Am. J. Crit. Care., May 1, 2006; 15(3): 269 - 279. [Abstract] [Full Text] [PDF]