Abstract P39: Withdrawal of Life Support and Do-Not-Attempt-Resuscitation Status After Successful Resuscitation From the National Registry of Cardiopulmonary Resuscitation
Background: Survival from in-hospital cardiac arrest (CA) remains low. Declaration of DNAR status and withdrawal of life supporting therapies (WLST) after ROSC during in-hospital resuscitation impacts survival to discharge. Reliable prognostic factors are established after post-arrest day 3. Pre-arrest and intra-arrest factors are less reliable predictors of outcome.
Hypothesis: Assignment of DNAR status and WLST occurs before reliable prognosis can be established.
Methods: We studied 16,623 consecutive, adult, index CA event survivors in the NRCPR database with DNAR and WLST information.
Results: After ROSC, 41% of patients were declared DNAR. DNAR status was made within 1 day of ROSC in 4248 (62%), 2–3 days in 885 (13%), 4 –7 days in 615 (9%) and after 7 days in 1150 (16%). Factors associated with DNAR status ≤3 days of ROSC are female sex (OR=1.21, 95%CI: 1.07–1.37), older age (per 10 yrs) (OR=1.29, 1.23–1.34), poor baseline Cerebral Performance Categories (CPC) score (OR=1.24, 1.15–1.34), longer arrest (OR=1.15, 1.08 –1.22), and epinephrine/vasopressin bolus (OR=2.94, 2.43–3.55). Factors not favoring DNAR status are black race (OR=0.74, 0.63–0.87), surgical illness (OR=0.66, 0.56 – 0.78), witnessed arrest (OR=0.63, 0.46 – 0.85), and ED arrest (OR=0.65, 0.51– 0.83). Active WLST occurred in 3784 (22.7%) of initial survivors. Care was withdrawn within 1 day of ROSC in 1,774 (46%); within 2–3 days in 635 (17%); within 4 –7 days in 503 (13%) and after 7 days in 872 (23%). Factors associated with WLST ≤3 days of ROSC are female sex (OR=1.24; 1.07–1.44), older age (per 10 yrs) (OR=1.14; 1.08 –1.20), poor baseline CPC (OR=1.16; 1.07–1.27), longer arrest (OR=1.20, 1.12–1.29), epinephrine/vasopressin bolus (OR=2.11, 1.65–2.69), pulseless electrical activity (OR=1.21, 1.03–1.43). Factors not favoring WLST are black race (OR=0.62, 0.52– 0.76), surgical illness (OR=0.79, 0.65– 0.96), ventricular fibrillation (OR=0.92, 0.77–1.1), and ED arrest (OR=0.59, 0.42– 0.82).
Conclusion: Majority of DNAR status and WLST were undertaken prematurely and the actions are associated with less reliable pre-arrest and intra-arrest factors. Limitations on care with WLST or DNAR status require longer observation period focusing on more reliable predictors of outcome.